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2012_0109_amended packet
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2012_0109_amended packet
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�� <br /> ft <br /> Finance Department, License Division <br /> 2660 Civic Center Drive, RN 55113 <br /> (651) 792-7036 <br /> Massage Therapist License <br /> New License Renewal <br /> For License year ending June 30 01 <br /> 1. Legal Name k 6fA/1 fij <br /> 2. Hone Address Meg <br /> 3. Horne Telephone <br /> 4. Date of Birth <br /> _.. � J02 � s+ <br /> 5. Drivers License Number <br /> 6. Email Address <br /> 7. Have you ever used or been awn by any name other 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 ad Tess of the licensed ICI s e Therapy E tablishment that you expect to be employed by.4__ <br /> a A&�Sc - . A) I /U <br /> 9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br /> including a minimum of boo hours in successfully completed course work as described in Roseville <br /> Ordinance 116,massage Therapy Establishments. <br /> 10. Have you had any previou massage therapist license that was revoked, suspended, or not renewed` <br /> Yes NO If yes explain in detail. <br /> License fee is 100.00 <br /> Make checks payable to City of Roseville <br />
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