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Attachment A � � �� T�_,�...►`"�� Finance Department, License Division 2660 Civic Center Drive, Roseville, MN 55113 (6S1) 792-7036 Massage Therapist License (Please Print Clearly} � New I�icense ❑ Renewal For License Year Ending June 30, �J S + 1. Full Legal Name {Please Print)� V y��,t� `� ` (I.ast) 2. Home Address (Street) 3. Telephane �._____�__ 4. Date of $irth (mmldd/yyyy} 5. Driver's Lioense Number _ 6. Ethnicify: 7. Sex: � .0 -fY}.�. ) (City) (Stats} {Zip) �Cell ❑ Home ❑ Work State of Issuance„_� _. .___. 8. Email Address ._ _ � _ � 9. Have you ever used or been knawn by any name other than the legal name give❑ in number 1 abave? �es ❑ No If Yes, List each fulI name a3ong with dates�!1d places where used. Y'�'� �%��..+� 1 T f! lt/�K� C�{✓� K l� n 4 1 U. Name and address of the licensed Massage Therapy Establishment at which you expect to be e loyed: � �- �.-�- �l �t `�I �' � C-�. � �- �16 �-c. t> � 4 � � � � 11. Have held revious massage thexapist licenses? If yes, in which city were you licensed? es �� .� � i �-l�s� �i'\- jr"� ❑ No 12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, suspended or not renewed? ❑ Yes No ❑ NIA If yes, explain in detail on a separate page. By signing beiow you aertify that the above information 'rs correct and authorize the City of Roseville �'olice Department to run your information for the required background checks. Date � � / 1 °' � "T Please print this form and mail or hand-deliver alang with a certified capy of a diploma or certificate oFgraduation from a school of massage therapy including proof o£ a minimuYn af 600 haurs in successfully completed course work as described in Roseville �rdinance 116, Massage Therapy Establishments. License Fee 'rs $100.00 Make checks payable to: City of Roseville