By signing this application, I:
- Swear that all statements by me on this form are true and complete to the best of my knowledge
- Am at least 18 years old
- Hold a comprehensive certificate of massage from a school recognized by the Minnesota Higher Education Board
- Am a member of good standing of the Minnesota Therapeutic Massage Network or the American Massage Therapy Association or other organization possessing the same or similar standards and having an enforceable code of ethics
- Have received a copy of Chapter 10 Article VIII of the Shoreview City Code
- Understand the conditions set forth for massage therapist licensees
- Understand that false statements or omissions shall be sufficient cause for rejecting my license
- Authorize the City of Shoreview to use this information to determine my suitability for obtaining a license.
PRIVACY NOTICE / 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 Shoreview.
2. The known consequences of supplying the requested information is that the information or further investigation could disclose information which could cause your application to be denied.
3. You are not legally obligated to supply the requested information. The known consequences of refusing to supply the requested information is that your request for a license cannot be processed.
4. 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 Minn Stat. 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.
5. Other governmental agencies necessary to process your application are authorized by law to receive the information provided.
6. The City is required by law to furnish some of this information to the Department of Labor and Industry and the Minnesota Commissioner of Revenue.
The undersigned, by signing this notice, acknowledges that he/she has read and understood the contents of this notice and has received a copy of this notice.
My signature constitutes agreement of the Tennessen Warning and this entire application.