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<br />4. List massage, acupuncture or similar business license history you might have (location, license number - if license had been <br /> revoked or suspended, please state the reason and the business activity or occupation subsequent to such action): <br />5. Name and address of a recognized school or institution that teaches the theory, method, profession or work of message, <br /> from which you have received a diploma and certificate of graduation for completing not less than one hundred (100) hours of <br /> resident course of study (at least seventy-five (75) hours of which shall be classroom instruction). (for masseur or masseuse <br /> application only) <br />6. Are you on probation or parole for a crime? DYes o No <br /> If yes, name the crime, the date and place of sentencing and the duration of your probation or parole. <br /> CERTIFICATION AND ACKNOWLEDGEMENT <br />I hereby certify that the information provided in this application is true and complete to the best of my knowledge and that <br />misstatements, false or inaccurate answers will subject me to disqualification for a City of San Leandro Massage Permit. I also <br />understand that the acceptance of my application by the City of San Leandro does not guarantee the issuance of a permit, and <br />that fees and costs are not refundable if denied. <br />Applicant's signature Date <br />Print Name <br /> OFFICAL USE ONLY <br />Fees I Photographs I Diploma or Certificate received by Date <br />Fingerprinted by Date <br />Police Department Approval Date <br />Permit Number <br /> Expiration <br />Police 1.0. Number Date <br />