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<br />" <br /> <br />MAR-26-0i MON 1,56 PM CTY OF FOREST LAKE <br /> <br />FH NO. 651 464 4968 <br /> <br />RENEWAL APPLICATION <br />FOR MASSAGE THERAPIST CERTIFICATIONILICENSE <br />IN THE CITY OF rOREST LAKE <br />ORDINANCE 448 <br /> <br />RENEWAL YEAR <br /> <br />MASSAGE LOCA nON/ADDRESS <br />aDultS/DA VS OF OPERA nON <br />NAME OF APl>UCANT <br /> <br />(fint) <br /> <br />(last) <br /> <br />(middle) <br />HOME TELEPHONE #: <br /> <br />DATE OF BIRTIf <br /> <br />SCHOOL AITENDED AND DEGREES RECEIVED: <br /> <br />LIST QUALIFlCA T10NS REQUIRED TO PRAcnCE MASSAGE: <br /> <br />LIST lWO (2) CHARACTER REnRSNCES WHO RESIDE IN WASHINGTON COUNl"Y: NA.\fES, <br />ADDRESS" 0.0. TE OF BIRTH <br /> <br />HAS APPLICANT EVER BUN CONVICTIID Of A ClUMIl. OTHER TIiAl'l A TRAFFIC <br />VIOLATION'? _YES --.-NO <br />IF YES, PLEAS" GIVE AN EXPLANATION ON A SEPAMTIl PIECE OF PAPER, INCLtJ"DlNO <br />TIME, PLACE Ai'lP NATUBll 01' SUCH CRIME OR OFFENSE AND DISPOsmON THJ:1\EOF. <br /> <br />THE APPLICANT SliAJ..L PROVIDS THl5I'OLLOWlNO lNFoRMA nON: <br /> <br />A. EVIDENCE OF APPLICANTS' BDUCATION lNCWDINO CONTINUINO fOUCA TION IF <br />APPLICABLE. <br />B. EVIDENCE OF APPLICANTS' QUALI1lCAnONS AND CHARACTER l\JlFIl~CES. <br />C, EVIDENCJ!, IN TIlE FOR..\{ OF A ClJ1IJ!.ENT CERTlFlCAlB FROM A LICENSED <br />PHYSICAN PRACTICING IN MINNESOTA INDICATING 'mAT SAID MASSAOE <br />THERAPIST WAB EXAMlNED AND IS FRBE Of ANY COMMlJNICABLE DISEASE n-iA T <br />WOl.a,D OISQUALn;v THE APPLICA."lT FROM ENGAGING IN 1111! PRACTlC OF <br />MASSAGS. <br /> <br />A RENEWAL CJ:iRTlFICATE WILL BS RSQl]lR.ED EACH CALSNDAR YEAR, ALONG WITH A <br />PHYSICAL EXAMINA nON CERTIFICATE, COMPLBTED APPUCATION AND RENEWAL FEE <br />OF $~o.oo. APPLICANTS wn.L STlUCTL Y COMPLY WITH ALL REGULATIONS <br />PROMULGATED BY 1HB CITY COUNCil OF FORBST LAX!. AND ALL ORDINANCES OF SAID <br />MUNICIPLA TV. <br /> <br />p, 4 <br />