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Y7YT Trif <br /> V I <br /> Finance Department, License Division <br /> 2660 Civic Center Dn"ve, R A4N 55113 <br /> (651) 792=7036 <br /> Massage Therapist License <br /> New License Renewal <br /> For License year ending June 30 <br /> 1. Legal Name + <br /> 2. Home Address <br /> 1 <br /> 3. Home Telephone �. <br /> a � <br /> 4. Date of Birth <br /> r r <br /> 5. Drivers License Number - - � jW ,.. <br /> 6. Email 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 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 by. <br /> Ma C'e t/ti <br /> 9. Attach a ceded 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 revolved, suspended,or not renewed; <br /> Yes No rX If yes explain in detail. <br /> License fee is 100+00 <br /> Make checks payable to City of Roseville <br />