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Finance Department, License Division <br />0 2660 Ci a Center Drive, Roseville, NW 55113 <br />(651)792-7036 <br />Massage Therapist License <br />(Please Print C1earIY) <br />New License ❑Renewal <br />For License Year Ending Jac 30, �fl <br />i. Full Legal Name (Please Print. <br />2. Home Add <br />(Strmt) <br />3. Telephone <br />4. Date ofBirth (mm/ddtyyyy)_ <br />5. Diver's License Number <br />6. Ethnicity: <br />7. Sex: <br />8. Email Address <br />ZI�EN.ZH.Fl <br />first {Middle) <br />pity (State) (zip) <br />Cell El Dome ❑ Work <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 A No If Yes, List each full name along with domes and places where used. <br />10. Name m and address of the licensed Massage Therapy Establishment at which you exnect try be em-Dloyed: <br />jlptO <br />fir <br />1 I . Have you held any previous massage therapist licenses' If yes, in which city were you fic .used <br />❑ Yes KNo <br />12. If you answered Yes to munber I i above, were any pious massage therapist licenses revoked, suspended or <br />not renewed? <br />❑ Yes ❑ No ❑ N/A <br />If yes, explain in detail on a separate page. <br />By signing below you car* that the above information is corm and auffiorize the City of Roseville Police <br />Department to run your fifformation for the required background checks. <br />{ e e <br />Signatare Date I ! <br />Please print this forms and mail or deliver along with a certified copy of a diploma or certificate graduation <br />from a school of massage therapy including proof of a minimum, of 600 hours in successfiffly completed course <br />work as descHibed in Rosevi <br />