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f <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-170314 <br />................... . . ...... . W <br />New License Renewal <br />For License-year, ending June 30 <br />1. Legal Name d y- ---1 0.. <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 .long with dates wid. places where used. <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />+ <br />9. Attach a ceitifi,ed copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum, of 600 hours in success fall y completed course, work as described in Rogeville <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10 Have you had any previous massage therapist license that was revoked, suspended, or not renewed?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 75.00 <br />Make checks payable to City of Roseville <br />