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' <br /> 'elm <br /> p <br /> d Vi <br /> Finance Department, License Division <br /> 2660 Civic Center Drive, Roseville, NM 55113 <br /> (651) 792-7036 <br /> Massage T License <br /> New License Renewal <br /> For License year ending June 30 <br /> 1. Legal Name a-be io&,) <br /> 10% h <br /> 2. Home Address ; IdOWE 0E <br /> 3. Home Telephone T <br /> 4. Date of Efi-th <br /> x <br /> 5. Drivers License Number <br /> 6. Email Address <br /> 7. Have you ever used or been known by any name other than the legal name given in number I above? <br /> Yes No If yes, list each name along with dates and places where used. <br /> -01a ,I- <br /> 1PI-ATIn <br /> oke-lS L <br /> i <br /> S. Name and address of the licensed a e Therapy JEstablishment that you expect to he employed by. <br /> 9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br /> including a minimum of 600 hours in successfully completed course work as described in Roseville <br /> Ordinance 1161,massage Therapy Establishments. <br /> 10. Have you had any previous massage therapist license that was revoked, suspended,or not renewed? <br /> Yes No—. If yes explain in detail. <br /> License fee is 100.00 <br /> Make checks payable to City of Roseville <br />