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Attachment A <br />�,�� ��,�.. ,,� ,„ . <br />�� � : <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />;,�, (Please Print Clearly) <br />fU New License ❑ Renewal <br />For License Year Ending June 30, Fi [� , , <br />1. Full Legal Name (Please Print) �I�I�'�,�i�..� ( � �(��(ne/ �� �rV ��'�,J <br />(Last) (First) (Middle) <br />2. Home Address_ <br />(Street) <br />3. Telephone _ � <br />4. Date of Birth (mm/dd/yyyy)_ <br />5. Driver's License Number <br />6. Ethnicity; <br />7. Sex; <br />8. Email Address <br />(City) <br />❑ Cell �Home <br />(State) (Zip) <br />❑ Work <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 ❑ No If Yes, List each full name along with dates and places where used. <br />��2�� � 1V(, . L�e. C't�v -e.��" -� C �'7(E� `- �C"� � �--- !v(, l�J <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />�.,5� �'�-��° «...� �e, I�l G 7 L.C:���,�c���as�v� l(,�� l�_ 1� <br />11. Have you held an previous massage therapist licenses? If yes, in which city were you licensed? <br />`�]. Yes ��' ( G���`/ ���'1d"CV [ �,UJ , �'�L `! (�'ZC�t,�� �� ❑ No <br />12. If you answered 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 bacicground checks. <br />Date � r� ` ( <br />Please print this form and mail 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 $100.00 <br />Make checks payable to: City of Roseville <br />