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Attachment A <br />��� � <br />�� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, NIN 55113 <br />(651)792-7036 <br />Massage Therapist License <br />�New License ❑ Renewal For the License Year Ending June 30, � <br />1. Full Legal Name (Please Print) �� ��I�l � <br />(Last) (First) (�iiddle) <br />2. Home Address <br />(Street) <br />3. Telephone <br />4. Date of Bitrth (,,,m dd yyyy)J <br />�. Email Address <br />� <br />6. Driver's License N�imber <br />7. Ethnicity: <br />8. Sex: <br />(CitY) <br />�Cell ❑ Home <br />— � � <br />(State) (Zip) <br />❑ Work <br />State of Issuance ��(�� <br />9. Have you ever used or been kno�vn 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 />. <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />N1 �.ssc�.� �7�c�� �� (�l l� �„ ne,�m trv ��. b s�v� il e, Nt 5�► I <br />1 L Have you held any previous massage tllerapist licenses? If yes, in which city were you licensed'? <br />❑ Yes �No <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, suspended or not <br />renewed? If yes, esplain in detail on the back of this page. <br />❑ Yes ❑ No �/A <br />The information that you are asked to provide on the application is classified by State law as either public, private or <br />confidentiaL All data, with the eYCeption of driver's license numbers. will constitute public record if and when the license is <br />granted. Our intended use of the information is to perform the background check procedures required prior to license issuance. <br />If you refuse to supply the information, the license application may not be processed. <br />By signing below you certify that the above information is correct and authorize the City of Roseville Police Department to run <br />your information for the required background checks. (Note: BackQround checks mav take u�o 30 davs to complete.) <br />Signature � ' Date <br />Please print this form nd ail or hand-deliver along with a certified copy of a diploma or certificate of graduation fi-om a <br />school of massage therapy including proof of a minimwn of 600 ho�n•s in successfully completed course ��-ork as described in <br />Roseville Ordinance 116, Massage Therapy Establishments. <br />License Fee is �100.00 (prorated quarterly) <br />�Iake checks payable to: City of Roseville <br />