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Finance Department, License Division <br />2660 Civic Center Drive, Roseville, M 55113 <br />(651)792-7036 <br />Massage Therapist License <br />(Please Print leanly <br />New LicenseEl Renewal <br />For License Year Ending June 30, ac j!j <br />1. Full Legal Name (Please Print) I A-V Ln <br />�nac�h-- - K"k. I I W KI e., <br />(Last) (First) L (Middle) <br />2. Home Address_ <br />Street itat -- <br />3. Telephone__ Cell ❑ Home ❑ Work <br />-- - -- <br />4. Date of Birth mm dd /yyy _ - — - <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 f4 No If Yes, Dist each full name along with slates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />�)arLusg - 7�Lzw�g- 1--'] � ip ---I C� ) I - _0 -x- -%I m*.,n R, r�L K - � I tZ .� C4 'o <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />❑ Yes _e _ __. No <br />12. If you ans wered Yes to number 11 above, were any previous 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 certify that the above information is correct and authorize the City of Roseville Police <br />Department to run your information for the required background checks. <br />Signature �� 6P Ig <br />Tease print this form email or hand - deliver along with 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 `0f 0 D A <br />Make checks payable to: City of oseill <br />