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jig i <br />Flounce Reps ent� License Division <br />2660 Civic Center Die, Rogue, MN 55-113 <br />(651) 792 -7034 <br />Massage Therapist License <br />cw Lice= Renewal <br />For License yeu ending June 30 <br />1. Legal N e <br />1% t <br />2. 'Home Address.­,, .. _ <br />3. Homo Telephone_ <br />4. ]date of Birth <br />5. Drivers License Number <br />6- Email Address <br />7. Have yop ever ur-p-d or bm known. by any name other d= the le pt nano giver in number 1 above? <br />Yes , — Ni If yes, list each name along with dates and plain where used, <br />Name e d addms of the 1i ased Massa 1rherati Y. Esta 'shmm that you exert to be employed by.- <br />9. Attach a oerfified copy of a diploma or mrtificate of graduation ftm a school of - massage therapy <br />including a. minimum- of 600 hours in succewfnlly wmplded course work as described in Roseville <br />Ordinanuz 116, massagc Thcrapy BsmbliZments. <br />10. Have you had amlo previous massacrr= ,herapig license that was revoked-, suspended* or not renewed? <br />Yes No _ If Y as explain M' dew 1. <br />License fee it, 75.00 <br />Make checks payable to C► of Roseville <br />7 <br />