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R1r„%�: <br />1� <br />Finance Department, License Division <br />266Q Civic Cenfer Drive, Roseville, MN SSI13 <br />(651)792-7036 <br />Massage Therapist License <br />New License ❑ Renewal � <br />For License year ending June 30, �2, D <br />1. Legal Name � <br />2. Horrce Address { <br />3. Home Telephone <br />4. Date of Birth <br />� <br />�� � �� S�j YI e, ��rSdYt � 1�. ��,[l� <br />� <br />� - �� - <br />� <br />r.� <br />S. Drivers License Number <br />. � , � <br />6. Ernail Address <br />: r, .�i � . , <br />� ,� � _ . - , <br />7. Have you ever used or heen known by any name other than the legal name given in number 1 above? <br />Yes ❑ No � If yes, tist each name along with dates and places where used. <br />8. Name and address of the licensed Massage Therapy Estahlishment that you expect to be ernployed by. <br />Je��n1,,. 1 ��jv.St � � � .��cr. _... <br />9. Have yoa had any previous massage tlzerapist license that was revoked, suspended, or not renewed? <br />Yes ❑ No� Iiyes, explain in detail on a separate page. <br />/� <br />Please print this form and mail or hand-deliver aiong with a certified copy of a diploma or certificate of <br />graduation from a school of massage therapy including a minimnxn of G00 hours in successfully completed <br />course work as descrihed in Roseville Ordinance 1] 6, Massage Therapy Establishments. <br />Finance Department, Licensc Division <br />2d60 Civic Cenier Drive <br />Roseville, MN 55113 <br />License fee is $100.00 <br />Ma.ke checks payable to: City of Roseville <br />