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DEC-16-��14 04:39 F�om: T�:6�17927�2� Pa�e:2�3
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<br />Finar�ce D���rtrn�pz, I,ic+�nse T�ivision
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<br />1V����a��e �'he:rapi�t I�icen�e
<br />�r�w Li�et►se ❑ l�.e�ewa� � '; �'olr tlae �.�ce�sc j�'cax ��4dxz�� .Tu,qe 3Q, "� ��
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<br />�. �'ula �.egal �7'at�e (F�leasa print�
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<br />2. �a1n�� �4,dd�ress
<br />(�tK�et} ; {�:iry) (5tatc) (�ip)
<br />3. Tele�k��i�� �_.._, . . ,��11 ❑ Home ❑ Wark
<br />4. Date of Bii'fh (�,/dd/�xYJ)
<br />5. Etnail Address
<br />6. I�xzvax's �icense Pdum6er
<br />7. Ethnicity;
<br />$. Sex:
<br />SCat� af Tssuanc�
<br />9. Have you ever used .�r b��� 1cnc��vn �y any �azrr�e otki�� ����,�; riae �e��R �arx�e �xve� �� �uAx�bex I abave?
<br />❑ xes ,�Tn ��` YGsy �,ist �aw� fuid r��tne �1ong wi�h dates az�d p�ace� w�a�xe used,
<br />�0. k�fa�xte �d addresa of the li�ensed Massa e Thcrapy E bliskrn�ent ak wy,AC:kA yC7y,ejt��ct to b� ���5�py�d:
<br />�I'��, i 5`��, ,�r� v�' f �, � �`� �:",���e,.✓ �`'�!'�- f(r��
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<br />11. Have you held an prcvi4�ts �lassage t�e�a��st ��ce#�ses? Z�`:yes, �� which city were you lic�nsed?
<br />�,'es ����✓; �' ❑ �in
<br />12, If you answered Y�s to �u�bex � X above, we�e any previaus tnassage therapi�t licenses r�v+�k.ed, suspended or not
<br />Kez�ewed? ��' yes, explain, in d�tail on the back af this �ra��,
<br />❑ Xes ,�"�T¢ 0 N!A ,
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<br />'�h� iT�fc��`txlat�p#� t�,at yuu ar� asked ta provide Qn the ap�li�atian is Gls�ssi��d by SR�t� law �s ett�ex publxc, p�d,vat�e o7r
<br />coz���dep,t�a�. ,pll data, witI� the exception of drivcr's liccz�se �u�be:rs, w��� eq�,st�tute puf���c recoxd �� at�@ wber� the licen�e is
<br />granted. Our intend�d use ofth� infarm�tio�. �s to pex�oz� t�e bac�ground check procadures required pri�r to iioense issuance.
<br />��you z'e�'use tq supply the i�formation, the iicense applic�t�an �ay �a¢ be ��•ocessed.
<br />By sign'tng b�1ow y4u cezrtify t�at t�e abqv� a�£orxnatipn i� cqrr�ct and authorize th� City ofRos�vill� Fcali�e De�arC�enz to �'u�
<br />your information fbrt t�e ;rec�uj�ed bac�xc�uz�d c�7,ec,�cs. � ote: Bficl��round checks mav talce up ta 30 davs ta aorrtvl�t�.)
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<br />�i�natur� �.,�� .��' L7�t�
<br />Please print this forttt and tt'lat� qx �aa�d-delivex a�oflg wAt�, a ce�•�i�ed cppy pf a djplot77ia ox certi�cate o� graduatFqn bro�m a
<br />sc��oal a�'zt7�as5a,�e t�,ezapy xneludin� prqofofa minimum r�f 60d lfours in successfully com�lezed cQurs� wark as desc�ik�ed i�n
<br />Raseville C7rdina�ace X 16, N��ssage �`�exapy �stab�xshrx�,��ts.
<br />License Fee is $100.00 (pru�rat�d qu�rterly�
<br />Make cheCka payabl� to: Cltj' 6f Ii�S9@VIIIE
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