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S E L-+ E <br />PNLN; <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792 -7034 <br />Massage Therapist License <br />New License <br />For License year ending June 30 e-5 ? � � <br />Or <br />1. <br />Legal Marne z:�3- z <br />2. Home Address- <br />3. Horne Telephone <br />4. Late of Birth <br />5. Drivers License umber <br />6. Er riail address <br />I/ <br />Renewal eK <br />7. Have you ever used or been known by any name otter than. the legal name given in, number 1 above? <br />Yes - - - - - - No if 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 />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 Roseville <br />Ordinance 116, massage Therapy Establishments, <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed?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 />Make checks payable to City of Roseville <br />