Laserfiche WebLink
/� <br />l�' <br />► <br />�� � <br />�� <br />Finance Department, Liceose Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651)792-7036 <br />Massa�e Thera�ist License <br />New Lice Renewal� <br />i � <br />Por License year ending June 30, =2.Q /¢ <br />1. Legal Name <br />2. Hame Address � <br />3. Home Telephone <br />4. Date of Birth <br />. <br />5. Drivers I�icense Number <br />6. Email Address <br />v <br />7. Have you 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 alang with dates and places where used. <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />5 �d �-U � �, r71N <br />Ss-� / z <br />9. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes ❑ No� If yes, explain in detaii 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 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 Depar�ment, License Division <br />2G60 Civic Center Drive <br />Roseville, MN 55113 <br />License fee is $100A0 <br />Make checks payable to: City of Roseville <br />