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S VAjW V I <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792 -7036 <br />Massage Therapist License <br />--- ---------- <br />New License Renewal <br />For License year ending .tune 30 GA <br />1. Legal ]Marne UA <br />2, Home Address <br />3. Home Telephone %F F - W r <br />4. Date of Birth <br />5. Drivers License Number <br />6. Email Address A <br />7. Have you ever used or been Zn by any name ether than the lega 1 nam e g i ven i n number ] above"? <br />Yes No If yes,, list each name along with dates and places where used. <br />8, Name address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />-- - - AAA 6 r, Li . R t) A t' ao� -0� <br />9. Attach a certified cap} of a diploma or certificate of graduation from a school of massage therapy <br />including a minirriuni of boo hoo.rs in successfully completed course work as described in Roseville <br />Ordinance 1 1 6, 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 have you had any previous massage therapist license that was revoked, suspended, or not renewed?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 />