Individual Massage Therapy A,lbertiville
Smog T ,n uvkm.ft city Ula.
APPLICATION FOR INDIVIDUAL
MASSAGE THERAPY LICENSE
COST: $SO Annually License No.
I. APPLICANT INFO
Applicant Name(First,Middle, Last):
Home Address:
City: State: Zip:
Home Phone: Cell Phone:
Height: Weight: Eye Color: Hair Color:
Employer's Name:
Employer's Address: Phone:
Is this the where you will be performing massage therapy services? Y� NN
If no,please list where you will be performing massage therapy services:
Have you been known by any name(s) other than the name above? Y❑ N❑
If so,please list the names,dates and places used:
Have you been convicted of a felony,crime or violation of an ordinance other than a minor traffic offense?If
so,list the date,place and offense involved in the convictions: 0 0
Please list all addresses where you have resided in the last 5 years:
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763-496-6801
CITY OF ALBERTVILLE ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
1
A,lbertiville
Smog T ,n uvkm.ft city Ula.
OCCUPATION INFORMATION
List the names,addresses and phone numbers of your employers for the last 5 years:
If you have been engaged in the operation of massage therapy services in the past,please list the name,
address,phone number and length of time you were involved in such activity:
II. TRAINING AND REFERENCES
Have you received 400 hours of massage therapy training from a bona fide school of massage therapy?
Please provide a copy ofyour certificate,diploma,etc. Y❑ N❑
If no,do you have at least one year of practicing massage therapy? Y❑ N❑
If no,will you be able to complete 400 hours of training within 2 years? Y❑ N❑
Please provide two references not related to you:
1.
2.
III. SIGNATURE AND OATH
I hereby state:
• The answers and statements given by me are true and accurate to the best of my knowledge and
belief.
• I understand that providing false information in this application may result in denial of a license.
Signature of Applicant Date
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763-496-6801
CITY OF ALBERTVILLE ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
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A,Ibertvillc
Small'rown uVIIng.1119 C1W urt.
BACKGROUND INVESTIGATION
CONSENT FORM
APPLICATION TYPE:
❑ Massage Therapy—Individual ❑ Liquor License
Date: ❑ Massage Therapy—Business ❑ Mobile Food Truck
(Ice Cream Vendor)
Last Name, First Name, Middle Name(full)of Applicant(please print):
Maiden,Alias or Former(please print):
Date of Birth: Place of Birth: Sex(M or F):
Month/Day/Year
Social Security Number(optional):
The undersigned, having filed an application with the City of Albertville for a business license, realizing that the
City has need to investigate the background and history of the applicant in order to better evaluate his or her
application does hereby authorize and request Wright County Sheriff's Office,MN Bureau of Criminal
Apprehension,every law enforcement official and every other person,firm,officer,corporation,association,
organization or institution having control of any documents,records,or other information pertaining to me
to furnish the original or copies of such documents,records and other information to the City or any of its
representatives to inspect and make copies of any such documents, records, and other information; I further
authorize any such persons to answer any inquiries,questions, or interrogations concerning the undersigned,
which may be submitted to them by the City or its authorized representative, I fully understand that the
information so obtained by the City may be used by it in its evaluation of my application.
I hereby release and exonerate any person who shall comply with the authorization and request made herein
from any and all liability of every nature and kind growing out of and in any way pertaining to the furnishing or
inspection of such documents, records, and other information.
Signature of Applicant Date
Subscribed and sworn before me,this day of 20
Signature of Notary Public
Notary Seal
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763.496.6801
CITY OF ALBERTVILLE ALBERTVILLE, MN 55301 WWW.CI.ALBERTVILLE.MN.US
A,Ibertvillc
Small'rown UWng.1119 C1W urt.
TENNESSEN WARNING
In connection with your request for a license,the City has asked that you provide information about yourself which
may be classified as private,confidential, nonpublic,or protected nonpublic under the Minnesota Government
Data Practices Act.This means that this data is not ordinarily available to the general public.Accordingly,the City is
required to inform you of the following:
1. The purpose and intended use of the information requested is to determine if you are eligible for a
license from the City of Albertville.
2. You are not legally obligated to supply the requested information.
3. The known consequence of supplying the requested information is that the information or further
investigation could disclose information which could cause your application to be denied.
4. The known consequence of refusing to supply the requested information is that your request for a
license cannot be processed.
S. A criminal charge, arrest,or conviction will not necessarily bar you from obtaining a license with the
City, unless the conviction is related to the matter for which the license is sought, according to
Minnesota Statute 364.03. However,failure to reveal the requested criminal information will be
considered falsification of the application and may be used as grounds for the denial of the
application.
6. Other governmental agencies necessary to process your application are authorized by law to receive
the information provided.
The undersigned, by signing this notice,acknowledges that he/she has read and understood the contents of this
notice and constitutes agreement of the Tennessen Warning and its application.
Applicant's Signature Date
CITY CLERK'S OFFICE 5959 MAIN AVENUE NE 763.496.6801
CITY OF ALBERTVILLE ALBERTVILLE, MN 55301 WWW.CI.ALBERTVILLE.MN.US