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i <br />! <br />r <br />!`���f. <br />�i. <br />Finance Department, Liceose Division <br />2660 Civic Center Drive, Rpseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />. ..... <br />, <br />New License [,i� Renewal ❑ <br />For License year ending June 30, � 013 <br />I. Legal Name }v�j <br />2. Home Address _ <br />� ----T � � / <br />3. Home Telephone <br />4. Date of Birth <br />5. Drivers Licensc Number <br />- �.- <br />6. Email Address <br />- o �., r <br />7. Have you ever used been known by any name other than the legal name given in numbcr 1 above? <br />Yes ❑ No [1�If yes, list each name along with dates and places where used. <br />8. Name and address of the licensed Massage Therapy Establishment ihat you expect to be employed by. <br />��0.ss�� ���,r��f�; 7 �� ; +�a'� ��`��rt�d�%�?,c�-� �,•� 1.���j_.�[� <br />� —._.. <br />9. Have you had an revious massage therapist license that was revoked, suspended, or not renewed? <br />Yes ❑ No� lf yes, explain in detail on a separate page. <br />Piease print this form and mail or hand-deliver along with a certified copy of a dipIoma or certificate of <br />graduation from a school of massage therapy including a minimum of 600 hours in successfully completed <br />course work as described in Roseville Ordinance 116, Massage Therapy Establishments. <br />Finance Department, License Division <br />2660 Civic Center Drive <br />Roseville, MN 55113 <br />License fee is $100.00 <br />Make checks payable to: City of Roseville <br />