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r <br />mift <br />Finance Dent, License Division <br />2660 Civic Center Drive, l o evffle, AIN 55113 <br />(651)792-7036 <br />Massage Therapist License <br />Please Print Clearly <br />New License ❑Renewal ) <br />For License Year Ending ,rune 30, o � LI <br />1. FuU Legal Name lease Print ` <br />i Last) <br />iddlel <br />2. Home Address _ <br />(Siieet) i tat (zip) <br />3. Telephone <br />4. Date of Birth mmlddlyyyy <br />5. Driver's License Number <br />6. Ethnicity: <br />� <br />.0 <br />r <br />. Sex. <br />8. Email Address <br />Cell ❑ Home ❑ work <br />State of Issuance <br />V <br />9. Have you ever used or been known by any name other than the legal name given m number 1 above"? <br />34Yes El No If Yes, List each full name along with dates and places where used. <br />cLn i _ V 1 I ., <br />10. Name and address of the licensed Massage Therapy E tahli hment at which you expect to be employed: <br />r <br />11. Have you held an <br />previous massage the ist licenses? If s, ir ch ci were ou license 4 <br />y F g mP t <br />❑ Yes Igo <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked suspended or <br />not renewed? <br />❑ des �-No El N/A <br />If yes, explain in detail on a separate page. <br />By signing below you certify that the above information is correct and authorize the City of Roseville Police <br />Department to run yaur infozmation for the required background checks_ <br />Signature Date 01)L Do t3 <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 600 hours in successfully completed course <br />work as described in Roseville Ordinance 116, Massage Therapy Establishments. <br />License Fee 100.00 <br />Mako rherkq navahle to: ON of l o�ille <br />