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Finance Department, License W 11 <br />2660 Civic Center Drive, ROseville, <br />(651) 792e-70 <br />Massage Therapist License <br />(Please Print clearly) <br />New License El ReneWaI <br />For License Year Ending June 309 IZ-6 j —q <br />1, Full .Legal lame (Please nt <br />2. Hone Addresi <br />3, Telephone <br />(Last) l. <br />street -- <br />i <br />4. Date of Birth (mm/dd/yyyy). <br />U <br />5. Driver's License Dumber <br />6. dmicxty: <br />7. Sex: <br />8. Email Address <br />Cell [ Horne <br />r <br />Diddle) <br />(State) <br />Work <br />I <br />State of Issuance <br />9- Have you ever used or been kno n bY anY name Other <br />� than <br />Yes the legal name lei number I above? <br />Yes, List each full name along with dates and daces <br />where used. <br />10. Name and address the licensed Massage Thera • <br />� Establishment at which you expect to be employed: <br />1 L Have you held any prVious mass a there Est �i • <br />Yes � ceises 1 yes, in which city were you licensed? <br />12. If you answered Yes to number 1 I abore, were <br />an <br />not renewed y pre iou massage therapist licenses revoked, suspended or <br />❑ Yes NO KN/A <br />If yes, explain in detail on a separate page, <br />By signing below you certify #hat the above infonnatio i <br />con -ect and urthr� the City of Roseville Police <br />Department to run your information for the required background aground checks, <br />lire C LA <br />� �W <br />Date <br />P <br />llap- <br />lease print th's form and mail or hand -d • <br />eli er along with a certified copy of a diploma or certificate • <br />from a school of massage therapy including proof of a ' . • p irate of graduation <br />word as described Roseville � ��� hogs m successfully completed co <br />ce 116, Massages Therapy stabiishments. � <br />License Fee is $100.00 <br />Make cheCks payable to: C4 ofRos ville <br />� <br />� " 3 <br />