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R1��''4�� . <br />1�� <br />Finance Department, License Division <br />2660 Civic Genter Drive, Roseville, MN 55113 <br />{651)792-7036 <br />Massage Therapist License <br />New License 0 Renewal ❑ <br />For License year ending June 30, <br />1. Legal Name <br />2. Home Address <br />3. Home Telephone , _ <br />4. Date of Birth <br />����f <br />5. Drivers License Number T _ _ — � " , �, -- ,_ �_ . <br />�, <br />6. Email Address <br />7. Have you ever used o en known by any name other than the iegal name given in number 1 above? <br />Yes ❑ Na If yes, list each name along with dates and places where used. <br />8. Name and address of the licensed Massage Thera Establisi�me t that <br />��-� C{ � � <br />9. Have you had any previous massage therapist license tnat was revoked, <br />Yes ❑ No��� If yes, explain in detail on a separate page. <br />expect to be <br />;(%�S�/�J 1'J') I'U , L <br />suspended, or not renewcd? <br />Please print this form and mail or hand-deliver along with a certif ed copy of a diploma or certificate of <br />graduation from a school of massage therapy including a minimum of 600 hours in successfully completed <br />course wark as described in Roseville Ordinance 1 l6, Massage Therapy Establishments. <br />Finance Department, License Division <br />2660 Civic Center Drive <br />Roseville, MN SSll3 <br />License fee is $1 OQ.00 <br />Make checks payable to: City of Roseville <br />� <br />�7� � <br />�J <br />