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2012_0109_amended packet
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2012_0109_amended packet
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A <br /> 10� f <br /> I <br /> Onance Departmen4 License Di I Vi 9 Ron <br /> 5 W <br /> 2660 Civic Center Dn"Ye, Roseville, M 55113 <br /> (651) 792&7036 <br /> Massage Therapist License <br /> --—----------------- <br /> New Lime kenew&l <br /> For License year ending gone 30 --)-0 <br /> 1. Legal Name <br /> 2. Home Adss _ <br /> 3. Ho=Telephonj ff 200 <br /> 4. Date of Birth <br /> 5. Drivers U sc Number <br /> 6, Email Address <br /> s <br /> 7. Have you ever used or been kn by any name other than the logo name given to number 1 above? <br /> Yes No If yes,list each name,along with dates and plate where used. <br /> 8. Name and addrm of the licensed Massage Ther y EstabUsh ment that you expect to be employ by. <br /> M. or <br /> 9. Attwh a cenMed copy of a diploma or certificate of graduation from a school pf mwsage,therapy <br /> including a minimum of 600 hours In sumessfully oompleted course work as descn1bed in RosevMe <br /> Ordinance 116#maser Therapy Establishmms, <br /> 10. Have you had any previous miqpage therapist licemse that was revoked,susparided.,or not renewed' <br /> Yes NO If yes explain 3n det 1. <br /> License fee is 100.00 <br /> Make chodm payable to City of Roseville <br /> as Pd 0L26)-T S9: <br />
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