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k rA <br />'roan a Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792 -7034 <br />Massage 'Therapist License <br />.. . ..... ........................ . . ...................... <br />New License Renewal <br />For License year ending .Tune 30 <br />1. Legal Dame, <br />2. Home Address <br />3. Home 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 -n ny name other than the legal name given in number l above? <br />Yes . _ N( y f yes, list each name along with dates and places where used. <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />- --- 1 1E11 t. - <br />b <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 hours in successfully completed course work as described in 1 osevillc <br />Ordinance 11.6, massage Therapy Establishments. <br />10. Have you had any previoulz massage therapist license that was revoked, suspended, or not renewed? <br />Yes_ No If yes explain in detail. <br />License fee is 75.00 <br />Male checks payable to City of Roseville <br />4 <br />