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2008_0128_packet
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2008_0128_packet
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12/28/2011 4:33:23 PM
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FM*ance Department,,' License Division <br />2660 Civic Center Drive, Roseviffie, MN 55113 <br />(651) 792-7034 <br />.6 License Massage Therapist <br />New License Renewal <br />For License year ending June 30 <br />(I t <br />1. Legal Name ki LYNN HTU-G.E <br />2. Rome Addres,, <br />3. Home Telephone— <br />4. Date of Birth <br />5. Drivers License Number- <br />6. Email Address <br />7. Have you ever used or been know i <br />n by any name other than the legal name given n number I above? <br />Yes Na if yes, fist each name along with dates and places where used. <br />S. Name and address of the licensed Massage Therapy Establishment that pct to be employed by. <br />flet'i I q-, so , <br />t%jta� OP <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 i 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 Have you had any previous massage therapist license that was revoked, suspended, or not renewed?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 %%- -%i i- If yes explami 'in detail. <br />License fee is 75.00 <br />It <br />Make checks payable to City of Roseville <br />
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