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f <br />i � <br />� <br />2660 Ci <br />New License � <br />For License year endim <br />1. Legal Name � <br />�`',���� �-r�r <br />�j�...✓ <br />�e Department, License Division <br />Cenier Drive, Roseville, MN 55113 <br />(65i) 792-7036 <br />Therapis� License <br />1 Renewal <br />June 30 / <br />� e � LL �� Jo�� � <br />2. Home Address _ �_ ,. �� ri c �� <br />3. Home Teiephone <br />i I 1 � r, <br />4. Date of Birth <br />� <br />5. Drivers License Number � i� -"• <br />G. Emaii Address <br />7, Have you ever used oz been <br />Yes No <br />S. Narne and address af the <br />�r_f/� 4`/ �'/�v�- <br />by a�nY name other than the legal name given in number 1 above? <br />/If yes, list each name along with dates and places where used. <br />Therapy Establ�s men that you e�cpect ta be em� <br />[° ��� ��1�/�il�c_J G�C/� . <br />- , - � ' ��.f�U�� �� �5^��3 <br />9. Attach a certified copy of a'ploma or certi�icate of graduation from a schoo� of massage t�erapy <br />including a minimum of 640 ho rs i� snccessfully completed course work as described in Roseville <br />Ordinance 116, massage Therap Establishments. <br />10. Have you had any previous assage therapist license that was revoked, suspended, or not renewed? <br />Yes No If yes explain in detail. <br />License fee is 1.Q0.0a <br />Make checks payable to City of <br />�o�d <br />