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L�� � <br />���= <br />Finance Depa�-tment, License Division <br />2G60 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, Z, ��� <br />1. LegalName ��.r..`�..� t��� L���-�'�Cl �>>c��-G^iG'` �� tJ�oa <br />2. Home Address <br />u <br />3. Home Telephone <br />4. Date of Birth <br />5. Drivers Licease Number <br />., - — <br />6. Email Address <br />�. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes ❑ No 7� If yes, list each name along with dates and places where used. <br />8. Name and address, of the licensed Massage Therapy Establislunent that you expect to be employed by. <br />9. Have you had ariy previous massage therapist license that was revoked, suspended, or not renewed7 <br />Yes ❑ No�] If yes, explain in detail on a separate page. <br />Please pri�t this form and mail or hand-deliver along with a certi .fied copy of a diploma or certificate of <br />graduarion from a school of massage therapy including a minimutn of 600 hours in successfizlly 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 SS I 13 <br />License fee is $100.00 <br />Make checks payable to: City of Roseville <br />