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��`�I. � <br />`�I . <br />„��►„ 1 , J J 1 <br />Finance Department, L�cense Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />New License � Renewal ❑ <br />For License yeaz ending June 30, �,� i�' <br />1. Legal Name �! 1 %l. � � � �J � Ci.. Frl �� j/1 �ir1 l �J <br />2. Home Address <br />� <br />3. Home Telephone <br />� . <br />4. Date of Birth <br />5_ Drivers License Number <br />6. Email Address <br />7. Have yo ever used or been known by any name other than the legal name given in number 1 above? <br />Yes [� No ❑ If yes, list each name along with dates and places where used. <br />�TG�I/�rii>��i �Iti_�. <br />and address ofthe licens�e��a�sage T�erapy Establishment tha�ou expect to be employed by. <br />' �{D�VWI e � t� � 5.5 � r� <br />9. Have you had any revious massage thera.pist license that was revoked, suspended, or not renewed? <br />Yes ❑ No� If yes, expZain in detail on a separate page. <br />Please print this form and rnail or hand-deliver along with a certified copy of a dipZoma or certificate of <br />graduation fror� a school of massage therapy including a minimum of 600 hours in successfully 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 55113 <br />License fee is $100.00 <br />Make checks payable to: City of RoseviiZe <br />