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h4w, S H - V -1 -1 A.14 <br />Finance Department, License WIion <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651)792-7036 <br />Mossage Th r pi License <br />n New License El Renewal (Please Print Clearly) <br />For License Year Ending June 30, oaf W di <br />1. Full Legal Marne (pje&W p nt ) Higgins Diane Marie <br />(Last) (First) (Middle) <br />2. Hone Address <br />(City) (State) (SIP) <br />Telephone - - DWI N Home El work <br />4. Date of Birth mm/dd/YM: <br />5. Driver's License Numb m State of Issuance <br />6. tWeity: <br />7. Sex: <br />8. Entail Address <br />9. Have you over used or been known by any name other ftm the legal one given in number I above? <br />W Yes C1 No If Yes, List each full nme along with dates and places where used. <br />Dime M. Higgins- Woodri 1991 -1 996 former r erd d Weans) <br />10. Name and address of the licensed Ma sage Therapy Establishment at which you expect to be ployed: <br />Elements Massage: 2100 Snelling Ave North -tit 66B Roseville, MN 55113 <br />11, Have you held any pious image therapist lioenses If yes, in which city were you licensed <br />01 Yes Bumwft, W D NO <br />12. If you answered Yes to number I I above, were any previous massage therapist licenses revoked, suspended or <br />not renewed' <br />yes N No 0 /A <br />If yes, a pia in in de l on a separate page. <br />By sig g below you cer fy that the move infonnation is correct and authorize the City of Roseville Police <br />lepamnt to zun your inormation for the wired background checks. <br />Signtare <br />iae Ll 113 <br />W W.ZL-1 Pleat a print this form and mail or h d -deliv with a certified copy of a diploma or mfificate of graduation <br />from a school of therapy including proof of a nuiminYum of 600 hours in su ces fcily completed coume <br />work as described in Roseville Ordinance 116. Massage Therapy Establishments. <br />mouse Fee 100.0 <br />Make checks payable to: City of Rose <br />