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2012_0109_amended packet
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2012_0109_amended packet
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ullf., <br /> AMP <br /> N"Vu N <br /> Finance-Department, License Division <br /> 2660 Civic Center Drive, Roseville, MN 55113 <br /> (651) 792=7036 <br /> Massage Therapist License <br /> New License Renewal <br /> For License year ending June 30 f <br /> 1. Legal Name "n6i Yano <br /> Cl-)-Cc, �Fn C <br /> 2 Home Address <br /> 3. Home Telephone <br /> 4. Date of Birth <br /> 5. Drivers License Number <br /> 6. EmA Address <br /> 7. Have you ever used or been known by any name other than the legal name given in number 1 above? <br /> Yes X No If yes,list each name along with dates and places where used, <br /> 8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed b, . <br /> r V A2Z <br /> i t\ATk%J <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 Have you had any previous massage therapist license that was revoked, suspended, or not renewed?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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