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11 ®r, <br />-- _ <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, NM 55113 <br />(651)792-7036 <br />Massage Therapist License <br />(Pease Print Clearly) <br />UCW License El Renewal <br />For License Year Ending ions 30, � I Ho(AoL <br />1. Full Legal Name (Please Print) , _ g=Z <br />(Lost) <br />2. Dome Address <br />(Street) <br />3. Telephone <br />4. Date of Bid nnVdd 3'yyy . <br />5. Driver's License Numbe <br />6. Ethnicity: <br />7. Sex; <br />8. Email Address <br />(First) <br />(City) <br />(Middle <br />(sue) <br />UP& {] Home Q Wark <br />Std of issuance <br />9. Have u ever used V011M known b any name other Om the legal name given in number I above? <br />0 Yes I f Yes, List each full mme along with dates and places where used. <br />10. Name and address of the licensed Massage 'Therapy Establishment at which you erect t be employed: <br />Lm—: � �Iy 02 1. 0 A- V <br />11. Haw you held any prev' massage theist licenses? if yes, in which, city were you licensed? <br />es o <br />12. If you answered Yes to number i 1 above, were any previous massage therapist licenses revoked., suspended or <br />not renewed? <br />El des R< [J <br />If yes, explain in detail on a wparste page, <br />By signing below you certify that the above information is correct and authorize the City of Roseville Police <br />Department to run your infoir n for the required background checks. <br />Si e IA 1 A3. <br />Pleat print this form and mail or hand - deliver along with a certified copy of a diploma or cerHficate of graduation <br />from a school of ma sup therapy including proof of a minimum of 600 houm in successfully completed course <br />work as described Mn Roseville Ordinance 116, Massage Therapy Establishments. <br />ILAceme Fee is $100,00 <br />Make cheep payable tot City of Roseville <br />