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`�� <br />��`—= <br />Finance Department, License Division <br />2b60 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-703G <br />Massage Therapist License <br />New License� Renewal ❑ <br />For License year ending ]une 30, �� �` � <br />l. Legal Name �� ci � �' F� ' <br />2. Home Address _ <br />3. Home Telephone _ <br />4. Date of Birth <br />S. Drivers License Nurnber <br />6. �mail Address <br />� <br />7. Have you ever use r been knawn by any name other than the legal name given in number 1 above? <br />Yes ❑ No If yes, list each narna along with dates and places where used. <br />8. �lat�� and addrgssQf the licensed Massage Therapy Establi,shrnent that,you exp�ct to be <br />/f//v <br />9. Have you had any previous massage thera.pist license that was revoked, suspended, or not renewed? ��� f� <br />Yes ❑ Noj� If yes, explain in detail on a separate page. � <br />Please print this form and mail ar hand-deliver along with a cert�fied copy of a diploma or certificate of <br />graduation from a school of massage therapy including a minimum of 640 hours in successfully completed <br />course work as described in Roseville Ordinance 11G, 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 checics payable to: City of Roseville <br />