ࡱ > bjbjR1R1 0[g0[g $ $ 2 2 2 P 4 $ 2 . ( ( ( . . . . . . . $ 0 93 x <. f* r( @ ( " f* f* <. Q. , , , f* R R . , f* . , , " , Pm * , . g. 0 . , 3 v+ v 3 , 3 , ( L ) 6 , V) , ) ( ( ( <. <. + ( ( ( . f* f* f* f* 3 ( ( ( ( ( ( ( ( ( X ` : INDIVIDUAL FORTUNETELLING APPLICATION NEW RENEWAL NAME DATE OF BIRTH ADDRESS BIRTHPLACE CITY, STATE, ZIP HEIGHT ___________ WEIGHT PHONE ____________________EMAIL ____________ EYES ____________ HAIR SOCIAL SECURITY # MARRIED _________ SINGLE HOW LONG HAVE YOU RESIDED IN SALEM? PLEASE LIST A FIVE YEAR EMPLOYMENT HISTORY: (DO NOT LEAVE BLANK) PLEASE LIST YOUR EDUCATIONAL BACKROUND: (DO NOT LEAVE BLANK) GIVE A BRIEF DESCRIPTION OF THE NATURE IF THE BUSINESS AND THE SERVICES TO BE PROVIDED: SIGNATURE OF APPLICANT DATED ***ANY FALSE STATEMENT MADE ON THIS APPLICATION IS GROUNDS FOR DENIAL*** FEE: $ _______ CORI COMPLETED: _______ CLEARED: DATE APPROVED: ***ANY FALSE STATEMENT MADE ON THIS APPLICATION IS GROUNDS FOR DENIAL. LICENSE IS VALID FOR TWO YEARS FROM DATE OF APPROVAL UNLESS SOONER REVOKED BY THE LICENSING BOARD. INDIVIDUAL LICENSES CANNOT BE USED IN ANY BUSINESS. CITY OF SALEM, MASSACHUSETTS LICENSING BOARD 93 WASHINGTON STREET 2nd FLOOR SALEM, MA 01970 GARY M. BARRETT, CHAIRMAN TEL. 978-745-9595 EXT. 41504 GARY SANTO, JR. FAX 978-744-1279 DEBORAH GREEL KIMBERLEY DRISCOLL MAYOR MELISSA PAGLIARO, CLERK OF THE BOARD SGT. MIKE BALL, SPEC. INVES. TO THE BOARD ' ( ) * + . Q R S T Y [ p v w ɹzozdXJXJXJXJXJXXXJ h