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ff to <br />/�Vz <br />�fi Attachment A <br />11% '40"16.,d V .9d 'd <br />Finance Department, License 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, 201w-1 <br />1. Legal Name <br />2. Hone Address <br />3. Hone Telephone _ <br />4. Date of irth <br />F ON <br />5. Drivers License Number <br />6. Email Address <br />0 <br />7. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes 0 No ® If yes, list each name along 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 />r► at A-714 +# rX + <br />IF <br />9. Have you had any previous massage therapist license that was revoked, suspended, or not renewed' <br />Yes [) 1 T ® 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 minimmn of 600 hours in successfully completed <br />course work as described in Roseville ille Ordinance 116, Massage Therapy Establishments. <br />Finance Department, License Division <br />2660 Civic Center Drive <br />Roseville,, X4N 55113 <br />License fee is $100.00 <br />Make checks payable to: City of Roseville <br />