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Attachment A <br />0 A91 <br />VA <br />Lse % <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792 -7036 <br />Massage Therapist License <br />New License 5d Renewal ❑ <br />For License year ending June 30, Z0/`Z <br />1. Legal Name �esLct'CC <br />2. Home Address _ <br />3. Horne Telephone_ <br />4. Date of Birth <br />5. Drivers License Number <br />6. Email Address <br />7. Have 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 laces where used. <br />7t) g'cn 6 r 1* 61 -ON 2-0 10 - 9�015 q., 1'-1 a s 3 c--kt s e 6-K V �1 ak <br />t' & If t f- <br />8. Marne and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />1 F A ILILri 0 Sre' I" -I- R0 Fa i v es Ave se� 40& I I <br />9. Have you had previous massage therapist license that was revoked, suspended, or net renewed` <br />Yes [[—] 1 If yes, explain in detail 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 Department, License Division <br />2660 Civic Center Drive <br />Roseville, Nils 55113 <br />License tee is 100.00 <br />Make checks payable to: City of Roseville <br />