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Finance Department, License Division <br /> 2660 Civic Center Drive, Roseville, NIN'55113 <br /> (651) X792-7036 <br /> Massage Therapist License <br /> New License <br /> Renewal <br /> For License year ending June 30 <br /> 1. Le gal Name liara( lil <br /> 2. Home Address - t <br /> 3. Home Telephone , <br /> 4. Date of Birth <br /> 5. Drivers License Number <br /> k <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.%C <br /> 8. Name and address of the lieens d Massage,Therapy Establishment ishment that you expect to he employed by.OLC 01 ke EV\VLA <br /> 4 0 (�G(LAr\ eLA) 3-U�tQ' t PZ() ck�-I VA 55) 13 <br /> It 19 () Ave, t <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 116, massage Therapy Establishments. <br /> 10. Have you had any previous massage therapist i ieense that was revoked, suspended, or net reneged? <br /> Yes No If yes explain in detail. <br /> License fee is 100.00 <br /> Make cheeps payable to City of Roseville <br />