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���� � ' � <br />� <br />Finance Department, License Divisian <br />2660 Civic Center Drive, Roseville, MN 55113 <br />{6S 1) 792--7036 <br />Massage Therapist License <br />{Please Print Clearly) <br />� New License ❑ Renewal <br />For License Year Ending June 30, ��� <br />l. Fu�! Legal Name (Please Print)�_�j� <br />� <br />2. Home Address <br />(First) <br />{Street} (City} <br />3. Talephane ___ �Celi ❑ Home <br />.�,�_.._..,--__.... , ..�--.�___ <br />4. Date of Birth {mtnldd/yyyy <br />i -- <br />5. Driver's License Nurnber <br />� s -- <br />6. Ethnicity: <br />7. Sex: <br />8. Ernail Address <br />{Middle) <br />(State) (2ip) ` <br />❑ Work <br />State of Issuance . �j� <br />9. Have yau ever used o,r been knowri by any name other than the legal name given in number 1 abave? <br />❑ Yes {� No If Yes, I�ist eaeh full name alang with dates and �alaces where used. <br />10, l�ame and address of the licensed Massage Therapy Establishment at which ou expect to be employed: <br />�lo� i� f?v� A�rl � ('E��v�P�� !�e^P /tihGL55cx9P Qosoia[[.�f�? �t�rv �� ('�lt�{ P�' . .3Zo <br />I l. Have you held any previous massage therapist licenses? If yes, in which Gity were you licensed? <br />❑ Yes ____ ._.__ __.__ :� Na <br />12. If you answered Yes ta number i 1 above, were any previous massage theraprst licenses revoked, suspended or <br />not renewed? <br />❑ Yes ❑ No ❑ N/A <br />[f yes, explain in detail on a separate page. <br />F3}� signing below you certify that t4�e abave informatian is correct and autharize the City of Rosevi�le Palice <br />L?epartment to run�your information for the required background checks. <br />r'i L <br />SignatureT�°���� � — _.�__. .��_�_______----- Date � � c,� � �� <br />� <br />Please print this form anci mail or hand-deliver along with a eertified copy of a diploma or certificate af graduation <br />from a schaol af massage therapy inc}uding proof of a minimum of 60Q hours in successfully cornpleted course <br />work as described in ftose�ville Ordinance 1 16, Massage Therapy Establishments. <br />License �ce is $lOQ.00 <br />Make checks payable to: City of Raseviile <br />