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ll <br /> 4 <br /> y. <br /> i <br /> Finance Department, License Division <br /> 2660 Civic Center Drive, Roseville, MN 55113 <br /> (651) 792-7036 <br /> Massage Therapist License <br /> New Licenst Renewal <br /> For Licenm yew ending June 30 – <br /> Lem Name 6 AP w Ar L g to wJ <br /> I Rome Address — <br /> 3. Home Telephon. _ <br /> 4, DaI of Birth <br /> 5* Drivers License Number <br /> 6. Email Address <br /> 7* Have you ever used or been known by any name other than the legal name given 'number 1 above' <br /> Yes No <br /> If fires, list each naive along with d&Ws and places where used. <br /> S. Marne and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br /> A g6C -JE:Aj,,,L.I i:E-,h,c2 <br /> 9. At h a certified c*PY of a diploma or oertaficate of graduation from a school of massage therapy <br /> including a minimum of 600 hours in succenfially cor np leted course work-as dewribed in Roseville <br /> ordinance 116,massage Therapy Establishments. <br /> Have you had any previous massage therapist license that was ravoked,suspen&A or not renewed? <br /> Yea If yes explain in detail* <br /> License feels 110.00 <br /> Make checks payable to City of Roseville <br /> :wO JJ 6S;=to t joa-j7T-oga <br />