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kC11 7TY T T74% <br />4ASH -V- I <br />Finance Department, License Division <br />2660 Civic Center Drive, RoseviRe, NIN 55113 <br />(651)792-7036 <br />Massage Therapist License <br />(Please Print Clearly) <br />N New License ❑ Renewal <br />For License Year Ending June 30, 2014 <br />1. Full Legal Name (Please Print) SCOTT - ,FILES JIITA LIIA <br />(Last) (First) Middle <br />2. Horne Address <br />(Street) <br />(City) (State) (zip) <br />3. Telephone A ❑■ Cell ❑ Home ❑ Work <br />4. Date of Birth inmldd yyyy) <br />5. Driver's License Number <br />6. Ethnicity: <br />7. Sex: <br />8. Email Address <br />State of Issuance <br />9. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />❑ Yes 9 No If Yes, List each full name along with dates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />ELEMENTS MASSAGE OF ROSEVILLE, 2100 SNELLING AVE.N ROSEVILLE, MN 55113 <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />❑ Yes N No <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, suspended or <br />not renewed? <br />❑ Yes ❑ No ■❑ NA <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,terun your info tion for required b ac n cheeks. <br />N, <br />0', <br />Date <br />Lo <br />Please print this form and mail or hand- deliver along nth 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 is $100.00 <br />Make cheeks payable to: City of Roseville <br />