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r <br />ft9re, " 4 -7Tf A�T-_q� <br />fro <br />__V X <br />IJ <br />KS, Finance Iep� trnnt, x ,tense Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792.7036 <br />Massage Therapist'License <br />New License ❑ Renewal <br />For License year ending June 30, "Zo 114 <br />1. Legal Name X JA_ <br />2. Hoare Address <br />3. Hone Telephone <br />4. Date of Birth <br />5. Drivers License Number <br />6. Email Address <br />V <br />7. Have you ever used erg known bar any name other than the legal name given in number 1 above? <br />Yes ❑ i.f es, list each name along with dates and places where used. <br />8. Marne and Wress of the licensed Massage Therap Establishment that you expect to be employed by. <br />C.- V'/ t n <br />9. Have you had n revious massage therapist license that was revoked, suspended, or not renewed? <br />'es 0 If yes, Cpl in 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 hogs 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 Tee is i vu.vu <br />Make checks payable to: City of Roseville <br />