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- IV, <br />Finance Department, Licensc jDxvision <br />2660 Civic Center Drive, Rosevffle, AIN 5511 <br />(651) 792-7034 <br />Massage Therapist License <br />........ . ....... <br />r <br />Now Lieensc Renewal <br />For License year ending June 30 <br />1, Legal Dame <br />2. Home Address <br />3. Harno Telephone _ <br />4. Date of $ice <br />Iwll W Y.lY - <br />f ! r•r� <br />5. Dnvers Lime Nunaber- <br />6. Ernall Address—, <br />7, Have you ever used or been known 1mv any barrio athcr than the legal name given in nurnber 1 above' <br />"fie � _ NO If yes, list each uame along with dates and planes where used, <br />1 <br />8. Kane and add �f e f icers $ssage Therapy 8stablishra t that you rxp t to be employed by- <br />Attach a certified copy of a diploma or certificate of graduation from a school of mass ge therapy <br />motud'gng a minimum of 600 hours in succesMlly mpl d coursc work as descr1W in Roseville <br />Ordinance 116, Massage 'berapy Estahlishmcnts! <br />10. Have you had ary previOu:g "'ierapist license that was revoked, suspended, or not rettewed? <br />Yes _ No. �--- If yes explain in dcWl. <br />Llei� ae fm is 7 ,C* <br />Make checks payable to Oty of PtosevUje, <br />f <br />