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MAR-�2-2�14 a�:�7 Frum: To:6517g27��� P��e;3•4 <br />Attachment A <br />�� <br />��� � � �� <br />�'inanc� Ile�artm�nt, Lic�nse �►avxs��� <br />2650 C'ivic �enter Drive, ROS�VIL�C� NIN ��1�.3 <br />��s�� ��z��o�� <br />:��s���� �'�t�ra�ist Lic��a.s� <br />(,Pl�ase 1Prirxt c,lea��aY) <br />�, Ne�v �.�cexxse � ��newal <br />Fnr Lioen�e Year Endi�a� J�u�� 30, � <br />1. Fttll Legal'�farrae (k'�ease �ri�t) ; 1,� <br />, (Last) <br />2, H.ome A4ldress_�_ <br />(StA'eet) <br />3. Tel�phon� <br />4, L7�t� of S#rrt� ��m/dd/YYYY)_ <br />�. Driver's Lio�nse NUttll�er <br />6. Ethnioity; <br />���� <br />�� <br />�� jxy� i (�tate] <br />❑ k�Xot�e ❑ Wark <br />(MiddIe) _ . ... ! <br />���P) <br />�tate �f issuance � � <br />7, Se�c: <br />$. ��ail A,ddress <br />k J V <br />9. Have yotf ever used or bee� ��uw�a by any name other than th� le$�� �a�7;a �ive� in �iumber 1 abvve? <br />���s ��Pq Z�j,'es, List e�tch full n�me &lotzg wAth dates and places where used, <br />10. �a[ne and address of Ch� licens�d 1V�assage �herapy Est�blishmetkt ai whkch yuu e�,pact ta be eniploy�d; <br />� �t <br />�-. 1 4�.� [�+ ���-� �...+._!4.-�7_� <br />V1�,�i�.� �,Vr�� �l �� �-��v w �_.�, ��1� <br />11. Have yau belc� ��y p�'ev�ous massag� therapist lic�n5�5? I�y��, ��1 hi�h oity were you li��ns�c�? <br />❑ i(�s � �Na <br />lZ. If you answ�a•ed a'es t� num�er 11 aUove, were auiy pr�vaous nnassage therapist licenses �revo�,�d, su�pend�d or <br />rtc�t .re�ewed? <br />❑ ifes ❑ No �N/A <br />��yes, e�plai� i►i detail on a s�p�trttte page, <br />k3y 5igt�i�,g balow you ��rti1'y th�.t tl�� �.h+�ve AT1�at�aii4n is corr��t afl� authari�e tl�e Caty a�R,aseville P41ice <br />Z7�pa!'tmea7�t,� run yow- inform�tic�n fpr t}�e t`equilred background ahecks. <br />Si��ature <br />W1 V'�-� <br />jJate � ..,.. �� �- ? � f <br />! <br />Plesse prirlt tt 'is �o�ttt. at�d}tnail ar hand-deliver alc�ng wx�h a 4e�tj�ed copy of a diploma or C�CCi�icate a� �R'�duatian <br />�om a schoc, af tnassage kl�er���y iz�cludin� proof af a tninimum of 6Q0 kzQurs in succ�s$fully �omplatad cau�se <br />wotk &s desc ibed i� �oseuille ��rdirl�nce 116, M�ss��e'�k�et'apy .�stablishrnents. <br />Licen�e Fee 9s $7OU.0� <br />Make cheeks �ayabl� #a; City o#'k�osevillQ <br />