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m <br /> it <br /> Fiffinance Department, License Division <br /> 0 a <br /> 2660 Civic Center Drive, Roseville, MN 55113 <br /> (651) 7924036 <br /> Massage Therapist License <br /> cw License Renewal <br /> For License year ending June 30 x�l <br /> 1. regal Name CIQ-.0 .� <br /> 2. Horne Address <br /> ;� IB <br /> 3. Horne Telephone T <br /> 4.- late of Birth <br /> 5. Drivers License Number. <br /> 6. Email Address <br /> 7. Have you ever used or been known by any name ether than the legal name given in number I above' <br /> Yes No � If yes, list each name along with dates and places where used, <br /> CVL <br /> 8. Name and address of the licensed ass e.Therapy Establi ent that you expect to be employed by. <br /> 9. Anwh a certified copy of diploma or certificate of graduation from a school of message therapy <br /> including a minimum of 600 hours in successfully completed course work as d ribed in Roseville <br /> ordinance 116,massage Therapy Establishments. <br /> 10+ Have you had any previo rn sage therapist license that was revoked,suspended,or not renewed? <br /> Yes No If yes explain in dam]. <br /> 3 <br /> License fee fs 100.00 <br /> 1 <br /> Make cheeps` to City of Roseville <br />