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j�� � .�:�� : <br />�... <br />Fi�nance Department, License Division <br />2660 Civic Center Drive, Roseville, MN SSl 13 <br />{651) 792-7036 <br />Massage Therapist License <br />(P3ease Print �learly} <br />� New License ❑ Renewal <br />For License Year Bnding June 3Q, ��� <br />1. Full Legal Name (Please <br />2. Home Address <br />3. Telephone � <br />(Street) � <br />4. Date of Birth (mm/ddiyyyy} <br />5. Driver's License Numbe <br />6, Ethnicity; <br />7. Sex: <br />8, �mail Address _ _ <br />� Cell <br />(First) <br />'{City) (State) <br />❑ Home ❑ Work <br />(Middle} <br />(ziP) <br />Stata of Issuance �n/ <br />9. Have you ever used or been known by any name other than the lagal name given in number 1 above? <br />❑ Yes � No If Yes, List each full narr►e along with dates and places where used. <br />1 Q. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />iir�1� �C i i�' � .e(/�u/?C .r,/p �r1�i� �RC.���i'8�1 ot,� YC�`Ci`/1, . �J�' 0 .Sn P.f�ir�A /��� S�P3�S , l���uf /� <br />�- _ /YJ�d's��3 <br />11. Have you held an previous assage therapist Iicenses? If yes, in which oity were you licensad? <br />(L1 Yes , `��� /L% ❑ No <br />12. If you answered Yes to nurnber 11 above, were any previous massage therapist i'rcenses revoked, suspended or <br />nat 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 inforrnation is correct and authorize the City of Roseville Police <br />Department to run your information for the required background checks. <br />Signature r�1 �9Z Date p� � 2� �. <br />Please print this form and maii or hand-deliver along with a certified copy of a diplama or certificate of graduatian <br />from a school of massage therapy including proof of a rninimum of 600 hours in successfully completed course <br />work as described in Rosevil�le Ordinance 116, Massage Therapy Establishments. <br />License Fee is �100.d0 <br />Make checks payable to: City of Roseville <br />