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M <br />JL <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651)792-7036 <br />Massage Therapist License <br />Please Print leanly <br />/New license El Renewal <br />' I 'A <br />Pon License Year Ending June 1�, <br />1, Full Legal Name (Please Print) �&Cty) eta <br />2. Home Address <br />3. Telephone _ ell ❑ Home ❑ Work <br />4. Date of Birth m n /ddl r _ - I - I I <br />5. Driver's License Number State of Issuance <br />6. Ethnicity: <br />7. Sex: <br />8. Email Address <br />9. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />❑ Yes .'l If Yes, Dist each full name along with dates and places where used. <br />10. lame and address ofthe icensed Mas age Therapy Establishment at which you expect t b employed: <br />1.2 R '% rt <br />46 W i A <br />.I <br />A-4 A _&.1 t14 <br />LJ <br />Ubb (4 <br />11. 1jayrwyou helo any previous massage therapist licenses? If yes, in which city were you licensed? <br />Ur Yes M � No 01 U'r <br />12. If you answered Yes to number r 11 above, were any previous massage therapist licenses revoked, suspended or <br />not renewed? <br />❑ des q&.-So ❑N/A <br />If yes, explain in detail on a separate page. <br />By signing below you cert' the above information is correct and authorize the City of Roseville Police <br />Department to run your ' ion for the reyuir background the ks. <br />Signature Date 0000, <br />Please print this firm all or hand/- deliver with a certified copy of a diploni 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 checks payable to: City of Roseville <br />