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R4CIT711 7TY T " .*9E V JL I j I Odlij Finance Department, License Division 2660 Civic Center Drive, Rosevffle, MN 55113 (651)792-7036 Massage Therapist License (Please Print Clearly) XNew License El Renewal For License Year Ending June 30, CPO 1. Full Legal Name (Please Print CAA_nn)nqk (I -Act) 2. Home Address (Street) 3. Telephone 4. Date of Birth (mm/dd/yyyy)_ 5. Driver's License Number 6. Ethnicity: 7. Sex: 8. Email Address An (City) (State) [KCell El Home ® Work inn AC.4,41a) (zip) State of Issuance Mo. 9. Have you ever used or been known by any name other than the legal name given in number I above? El Yes Y4 No If Yes, List each full name along with dates and places wbcrc used. ame and address of the licensed Massage Therapy Establishment at which you expect to be employed: 1'ef_ e, 14i ci LavpP_nittKr AvQ VJ co�-%�Jj %J 11. Have you held an e ous massage therapist licenses? If yes, in which city were you licensed? Yes x I Y p l zr' , " N P Le- " M', No 12. If you answered Yes to number I I above, were any previous massage therapist licenses revok4 suspended or not renewed? C1 Yes )I�No 0 N/A If yes, explain in detail on a separate page. By signing below you certify that the above information is correct and authorize the City of Roseville Politic Department to run your information for the required background checks.. Signature CLC k-1 -A- Date /'�a o m id* or hand - deliver ith a certified copy of a diploma or certificate of graduation 0 1 1 Please print this form and er a14) P from a school of massage therapy including proof of a rn xYimum of 600 hours in successfully completed course work as described in Rnseville Ordirmce 1161 Massage Therapy Establishments. License Fee is $100,00 Make checks payable to: City of Roseville