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Attachment A <br />/� <br />1�'� <br />��� <br />Finance Department, License Division <br />26b0 Civic Cen�er Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />New License j� Renewal ❑ <br />� Z� i � <br />For T.icense year ending .Fune 30, _ <br />1. Legal Name � � �� , , <br />2. Horne Address _ <br />�s <br />3. Home Telephone _ <br />4. Date of Birth <br />5. Drivers License Number <br />6. Email Address <br />7. Have you ever use r been known by any name other than the legai name given in number 1 above? <br />Yes ❑ No, If yes, list each name along with dates and places where used. <br />8. Name and address of the licensed Massage T'herapy Establishment that you expect to be employed by. <br />4.a�.� �c ��. <br />9. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes ❑ No(� If yes, explain in detail on a se}�arate page. <br />Please print this form and rnail or hand�deliver along with a certified capy af a diploma or certifcate of <br />graduation from a school of massage therapy incluciing a minimum of 600 houts in successfully completed <br />course work as described in Roseville Ordinance 116, Massage Therapy �stablishments. <br />Finance Department, License Divisfon <br />2664 Civic Center Drive <br />Roseville, MN 551 i3 <br />License fee is $100.00 <br />Make checks payable to; City of Roseville <br />