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a <br /> _ W <br /> y -f <br /> New Liconse <br /> Finance Department, License Division <br /> ivic Center Drive, Rosevilleg DO 55113 <br /> 2660 C' <br /> (651) 792-7036 <br /> Massage Therapist License <br /> �-------------------- I ff--------- <br /> Renewal <br /> For Lt nse year ending June 30 ' <br /> 1. L IN n t <br /> 7,, Hom Address <br /> 3, Houma Telephone <br /> 4. Deft of Bhth <br /> S. Drivers License dumber.��r.�� � - <br /> P <br /> 6,. Email Addr= <br /> 7, iHave you ever used or been Drown by any name other d=the legal name given in number I ah ? <br /> Yes If fires, list eaoh name along with dgtes and places where u9W* <br /> e and add= fl Tbera lflishmnt tkrot 'nly lam. <br /> i <br /> 1 � <br /> 9. Aftch a ca6fied copy of a diploma or Certificate of graduation fmTn a school of manage theMY <br /> including a minimum of 600 hours in successfully rapie d COurm work w ducribed m Rosovffle <br /> Orlin l l 6#nn sage Therms Es%blishments. <br /> 10. Have you had any previous 7Me therapist flotnsa that was revoked,suspended)or not mewed? <br /> yes No ify�,s explain in mil. <br /> Lice=ft is 100,00 <br /> Cake cherks payable to City of Roseville <br /> 4 <br /> �� :a6 PCj 0MdL26.LTS9:01 :wOJJ 97:20 T T02-ST-030 <br />