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u <br /> W <br /> 4, rc <br /> fine Department, se Division <br /> 2660 Civic Cent'Drive, Roseville, MN 55113 <br /> (651) 79-24036 <br /> Massage Therapist License <br /> NVW Unse 'Renew <br /> For Ucenso rm ending,dune 30 <br /> 1. Legal Name �r � <br /> Y <br /> I <br /> 2. Home Address <br /> a� <br /> 3. Homc'telephone <br /> 4. Date of Birth <br /> s �A07,. <br /> 5. Drivm Li nse Number - <br /> 6. Em Address <br /> 7. fhve you ever used or been known by any name ether than the legal name wren in numbtr 1 above? <br /> Yes NO %4, If yes list cacb name along with dates and plam where used. <br /> 8. Nam d address of th usage Therapy Establishment that you `pew to ho employed by.5ct <br /> 9. Attach a certified copy of$diploma or certificate of graduation fr=a school of massage thorapy <br /> including a rflnimum of 600 hours in suemsfully completed course work as desaibed in RmviUe <br /> Ordinance 116 ncmpy Establishments. <br /> 10. Have yob had any previous m age therapist lic�-:n a that was revo d,suspcnded,or not renewed? <br /> Yes No If yes cxpl in in deWIT <br /> n <br /> License fee is 100.00 <br /> Make ohm payable to City of Roseville <br /> m <br /> � �� OdL26dL TS9:01 w a J <br />