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PON C1 7TT T <br />.�Ljy4h�ffi V I 141 0 It <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651)792-7036 <br />Massage Therapist License <br />(Please Print Clearly) <br />rN? <br />e w License ❑ renewal <br />For License Year Ending Jane 30, <br />r <br />1. <br />Full Legal Name (Please Prints <br />Last <br />First (lidrlle <br />2. <br />Horne ddres <br />(Street) <br />it (State ) (Zip) <br />3. <br />Telephone _ ell <br />❑ Borne ❑ Work <br />4. <br />late of Birth I m/dd/yyyy _ <br />_ <br />5. <br />Driver's License Numbe Numb <br />State of issuance <br />6. <br />Ethnicity: <br />7. <br />Sex: <br />8. <br />Email Address <br />9. <br />Have wu ever used or been known by any narne other than the legal name given in number I above? <br />es ❑ No If Yes, List each full name along with dates and places where used. <br />��- <br />"AsprN <br />tc1W0.-,-W1-3 rrvi <br />10, Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />PIC,�P,+X- rh/KSn..0.-,. 7 1 (30 5::�,] I I'f\, Akk, A I '-Ve1V_V � lie <br />11. I ve you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />Yes VC_. �) ❑ NO <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revolted, suspended or <br />not renewed? <br />es ❑ No ❑ N/A <br />1f yes, explain in etail on a separate page. W14 °� <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 N Date -d"5 <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 boo 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 />�13 <br />