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t <br />LE <br />V"" <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792 -7034 <br />Massage Therapist License <br />New License Renewal <br />For License year ending .tune 30 <br />1. Legal Narne <br />r <br />2. Hor-r-re Address--­,- <br />3 . Home Telephone <br />4. Date of Birth <br />5, Drivers License Number <br />6. Email Address <br />J • <br />7. Have ­-%31 %31 giver used or been known by any name other than the legal name given i n number 1 above? <br />Yes No_ _ If yes, list each name along with dates and places where used. <br />S. Name and ad ress� f t1 3e 1'cens d M a e T rapy Establis nt that you e e t to b emplo ed by. ��] Vj. <br />/ r <br />. Attach a certified copy of a diploma or certificate of graduation frorn 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 Have -iny p revi ou - therapist license that was revoked, suspended, or not renewed?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 />01 <br />