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Ii <br /> Finance Department, License Division <br /> 2660 Civic Center Drive, Roseville, MN 55113 <br /> (651) 792-7036 <br /> Massage Therapist License <br /> New License Renewal <br /> For License year ending June 30 <br /> 1. r <br /> Legal None <br /> 2. Horne Address <br /> 3. Home Telephone- - <br /> 4. ]date of Birth <br /> 5. Drivers License Number r- _ <br /> 6. Email Address <br /> 7. Have you ever used or been kn by any name other than the legal name given in number 1 above? <br /> Yes No If yes, list each name along with dues and places where used. <br /> . t <br /> 8. Larne and address of the licensed us age Therapy Establishment that you expect to be employed by. <br /> t f <br /> 9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br /> including a minimum of boo hours in successfully completed course work as described in Roseville <br /> Ordinance 116.massage Therapy Establishments. <br /> Have you had any previous massage therapist license that was revoked, suspended,or not renewed?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 loo.o 0 <br /> Make checks payable to City of Roseville <br />