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or <br /> oil j <br /> Finance Department, License Division <br /> 2660 Civic Center Drive, Roseville, MN 55113 <br /> (651) 792-703 <br /> Massage Therapist License <br /> New License Renewal <br /> For License year ending June 30 <br /> S <br /> 1. Legal Name <br /> 2. Home Address <br /> � A, �r <br /> 3. Horne Telephone <br /> 4. Date of Birth <br /> 5. Drivers License Number <br /> 6. Ismail Address <br /> 7. Have you ever used or been kr nwn by any name other than the legal name given in number l above? <br /> Yes No I If yes, list each name along with dates and places where used. <br /> 8. Name and address of the liven ed Massage erapy Establishment that you expect to be employed by. <br /> (X3 3 CAGL - ti r <br /> '• t <br /> 2- 1'g C) <br /> UVV)EP <br /> s 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 Have you had any previous massage therapist license that was revoked}suspended, or not renewed?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 />