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Attachment A <br />1.�� ' . <br />� <br />Finance Departmenf, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(6S1) 792-7036 <br />Massage Therapist License <br />New License � Renewal ❑ <br />For License year ending June 30, L� 1� <br />1. Legai Name Laura Marie Pdmus Quamme _ _ __ <br />2. Home Address <br />3. Home Telephone <br />4. Date of BirEh <br />S. Drivers License Number <br />6. Email Address <br />7. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes 0 No ❑ Tf yes, lisi each name along with dates and places where used. <br />8. Name and address of the licenseci Massage Therapy Establishment that you expect to be employed by. <br />Mind Body 8 Soul Wellness Center 2201 Lexington Ave Norih Roseville, MN 55913 <br />9. Have you had any previous massage therapist license tha� was revoked, suspended, ar not renewed? <br />Yes ❑ No❑■ If yes, explain in detail on a separate page. <br />Please print this form and mail or hand-deliver along with a certified copy of a diploma or certificate of <br />graduation from a schoal of massage therapy including a tninimum of 600 hows in successfulty completed <br />course work as described in Roseville Ordinance 116, Massage Therapy Establishments. <br />Finance Deparhnent, License Division <br />2660 Civic Center Drive <br />RoseviIle, MN 55113 <br />License fee is $100.00 <br />Make checks payable to: City of Rosevi�le <br />