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owe <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 />• 201For License Year Ending June o, <br />1. Full Legal Narne Please Print re, <br />iT - a &\ !7't! \ 11t f _ -1 1 _ It <br />2. Hone Address <br />(Street) <br />3. Telephone _ <br />4. Date of Birth ldd/yyyy) - <br />5. (river's License Number <br />6. Ethnicity: <br />7. Sex: <br />8. Email Address Must Be Legible <br />(City) ! (State}­ - (zip) <br />ZCO'�'ell ❑ Home ❑ Work <br />State of Issuance <br />9. Have you ever used or been known wn by any name other than the legal name given in number 1 above? <br />0yes ❑ No If Yes, List each full name along with dates and places where used. <br />�. , �� Zo <br />A- <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />lVe <br />l <br />11. Have you held any previous massage therapist licenses? If yes, in why city were you license 9. <br />❑ Yes o (,4. <br />I � 1 cj r, E Y" <br />12. If you ans wered yes to nu l evw ve, were any previous massage therapist licenses revoked, suspended or <br />not renewed? If yes, explain in detail on a separate page. <br />❑ Yes ZNo ❑ N/A <br />By signing below you certify that the above information is correct and authorize the City of Roseville Police <br />Department to run your information for the required background check. <br />Signature -.0 0.--7 Gro-�� <br />ZL3a<--e /D L <br />Date <br />Please print this form and mail or hand - deliver along with a certified copy of a diploma or certificate of graduation <br />from a school of massage therapy including proof of a minimum of 60 hours in successfully completed course <br />work as described in Roseville Ordinance 116, Massage Therapy Establishments. <br />License Fee is $100.00 <br />Make checks payable to; City of Roseville <br />