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`. <br />T I I --j-T -j I j <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 <br />1. Legal Larne (-�O �� T 1"1KA- <br />. Horne Address ' <br />Hone Telephone <br />4. Date of Birth <br />5. Drivers License Number , . <br />6. Email Address X-loek ej / 1A A! 7 A/ 4 A4, <br />7. Have you ever used or been known by any name other 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 />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course work a s described in Roseville <br />Ordinance 1 l , massage Therapy Establishments, <br />10. Have you had any previous massage therapist license that was revoked', ed', uspende.d, or not renewed? <br />'es No If yes explain in detail, <br />License fee is 75.00 <br />Male checks payable to City of Roseville <br />