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r/� <br />�+inance Department, License Division <br />2660 Civic Center Drive, Raseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />New License ❑ Ret�ewal,� <br />For Liceuse year ending 7une 30, �- �/ 7 <br />1. Legal Natue � 1 i�z ��� C G�iGa �1 S �C �q,N,� <br />2_ Heme Address _ <br />/" <br />3. Home Telephone � <br />4. Date o��But�i <br />_ � <br />5. Drivers License Nurt�ber <br />6. Email Address <br />0 �'1 <br />i. Ha�c you cvrr used or bee�i i�ow� by auy nurie Uthc�- tl�i tl�e ie�al uaiue givcr� iu nutuber 1 rbnve? <br />Yes � No ❑ If yes, list each nauie alon� with dates and lac whe�•e «sed.. <br />a` � � i �a% ��5 u. <br />�- --- , <br />8. me and address of the licensed Massa e Thes�apy Establis ent that you expect to be employed by. <br />��'—e � o ' s ; r l�-�3ei LLC <br />9. Have you liad auy previous massage diera�ist �icense that was revoked, suspe�ided, or not renewed? <br />Yes ❑ No� If yes, �xplain in detail on a separate page. <br />Please priaat t�is form a�d mail or liand-deliver along with a certified copy of a diploma or certificate of <br />duativn irvm a sc��ool of massage therapy includin a rninimum of 600 hours in successfuIly Cample <br />coiu�se wcnk as dcs�Y r ui o�ev a Osdivauce 116, Mt�s�e�e ThCrapy Es�ta • u�rts. <br />Finance Deparhxieni, License Divis�vn <br />2660 Civic Ceut�r Dti�e <br />Rosevil�e, MN SS113 <br />Licc�ise fce is $100.U0 <br />Make cl�ecks pa.yable ta: City of Raser+ille <br />�4f re u.� on �/.� <br />a-� ��r r�t r!C <br />� J � <br />