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��r�� ,� <br />Fieance Department, License Divi,sion <br />26bD ��vi� C��t�x ��iv�, It�s�vill�9 MN 5S� 13 <br />(6�1) 792-7036 <br />Ma�sage Therapi�� L�cense <br />New Licc�� Rencw�l [� <br />Far License year enc�iug Jtwe 30, �� <br />1. Lc�r�l N�us� ����SA �� S l �� <br />2. Hvme Address <br />3. Hame Telephone _ <br />�. D�C U�Sltiti <br />�. Drivers License Nwnber <br />G, Emai� Address <br />7, H�vn nu �ver CQ �?Y L)CC11 KIlUWIl tiy Hilj/ Il'dII1C qi11G7 i�iCl L�1C �C�,'dI I1idf11C �1YCIk ]IL 7►LttI1�1C1' I FibOMC� <br />Y�s [� Na� If y�.s, �ist �ach name a�ong with dates and places where t�. <br />8. Nam� and address of the licensett Massape Therapy Establishme�t t�at ymt e�cpeci to be e�p�oyed by. <br />� �eu c,� U�.c- �s �--�� L t �c� �rE . <br />9. Have ou h�� any previous massage tl�er�pist licentse that was revoked, suspended. or nat renewed? <br />Y� � Nt� Ifyes, eacplain in dctail on a s�parate p�ge. <br />Plca�se print tlus form aud maiJ ox hanei-deliver along with � certified copp of a diploma or cearti�cate of <br />�d��a�inn �rom a scl�aol o�m�ssag� th�y inc3u�g � m�imum of 6t�0 haurs in success�ily eompl�d <br />Ci1UI'�C' W[11�{ [i5 C��YCl'lEk� 131 RU�CV1uC OI(13I1ti114'C i 1G, Mx��agG Thcxa}�y E��tabli�huic:ut�. <br />�inence I)�p�tm�nt, Lic�nse �iVisinn <br />2660 Civic C�trr Driv� <br />RaseviIlc, MI�fi SSi i� <br />Lic;�e Zea ix �IQ4.00 <br />1VIa1� cliocl�s payabde to: City of Roseville <br />