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0,0,A', <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 Y. <br />For License year ending June 3� c2no _ _- _ <br />1. Legal Dame 5:mah <br />2. Home Address <br />3. Hone Telephone <br />4. Date of Birth <br />5, Drivers License Number <br />6. Email Address- <br />7. Have you ever used or been known by any name other than the legal name given in number l above? <br />Yes No if yes, list each name along with dates and places vwherc used. <br />S. Name and address of the licensed Massaae The -rare Fetes <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 600 fours in successfully completed course work as described in Roseville <br />Ordinance 1 1 6, massage Therapy Establishments. <br />10. Have you had anv nreviot— --#%— f'%-4.rapist I icense that was revoked, suspended, or not renewed?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 />