Laserfiche WebLink
Finance Department, License Division <br />2660 Civic Center Drive-, asevWe, MN 55113 <br />(651) 792 -7034 <br />Massage Therapist License <br />New License Renewal <br />For Liceme year ending June 30 <br />s <br />1. l all Name � ti <br />2. Homo AJdr *v. <br />3. HOW Telephour. <br />4. Date of 13lh <br />5- Drivers Li nsc Nurnt ; <br />6. Em-ail Address <br />C U <br />7. Have you ever used or he— -Im name other d= the legal name given in numb 1 above? <br />Ye,-- ' ;f yers, list eaob name along with & and places where used. <br />8. Name a address of the lice-t d Massey gimpy F-stabllahment that you expect to be employcd by, <br />ti k <br />9. Au =h a cerdfied copy of a diploma or Geitificate of graduation from a school of mamage therapy <br />including a m im=am of 600 hours in su ssfully wrnpleted coursr, work as dcsm-bed in Rosevillo <br />Ordinance 116, massage Tb exapY mb1 i shw tits . <br />10. Have you had any► previous massao therapist fice i that was revoked, syspendcd, or not renewed? <br />des <br />No If yes flab in del. <br />'YWLi .rwr iV JJI <br />1 <br />Lxcr,mc foo is 75.00 <br />Mike checks payable to Cky of Rosevgle <br />