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�....� <br />Financ� b�partnlent, LiGess�e Divisi�n <br />�6�0 �iv�� �enter �)rrv�, ���eville, lU� SSy1� <br />(���) ���—�o�� <br />;�.a����e T�erapa�t �.����►�� <br />��'l�ase krint Glearly) <br />'�23ew �.+C�ase I� �OnCVU:�1 <br />Fnr Cioense Yesr E.ndin� ,1u�e 34, r�r'°�'l �. <br />l. Fu�l �.e��l ]Vame (F►ease �rint) ��,� <br />��,ast) <br />2. T�om� Addr�s� <br />(�a��et) <br />3, 7clephb�i� � <br />4. T�ate of �inh (rnr�,lddlyyyy}�_ <br />5. �irive�''S T-icensE Nltmber <br />�. �[f1lliCit�_ <br />7. SzX: <br />(First� <br />(�a�3') <br />�e►1 [] �otre <br />� <br />�. <br />(h�ti Idle) ' <br />:-- .-� . ..", ,,. <br />�ytp�e� R�.,k: <br />�] yVor� <br />/� <br />�ta[,� oE'Tssuanc ,_„J�'C!� <br />S, �m2i1 Aadr�ss J <br />� — <br />9. Havc yoa cvar u,�Gfl ar heen knnWn 6y Pt�y ri�me other Yh$n t.he l���l n�ut� gi'Ven in nun�ber I <br />Q��S �� ��1t�s, �isi Cach ft�11 n�m� sE4ng with dates �nd pl�Ges v�rhf.'r� <br />l4, T+1'ame and address of the litensed lvtassage Therapj� F,�[�blishment at'�Iti�h y�+�+ �pEC� �� b� ��1¢yed: ; <br />� (;) 'c (�c.►e.. c�s�� I1.�. iY�� � i l� <br />1!. H�'vd y4u held any previou� ma����e r,3�erapist lioenses? lf y�s, in �hich city Vvere you licens�P . <br />�Y'�5 �t l.� ��`� , _ j� ]Vo <br />t�, 7fyou ansurered Yes to nUmber ! 1.�bt�ve, were any �t�'vitsus m�ssage th�rapist kic�ns�s 3'ev�k�d, susp�nd�d or <br />not renewed� <br />� Yes 1�10 � N�� <br />tf yes, explain i.n d�t8i1 on � S���ra�e paga. <br />By si�nVng b�iow y8u eestify that th� ahavt� infarmatian is toftect and suthorize the �iLy of Roseville ❑liCe ; <br />Uepartm�ent to run your in.farmati n or #h� requir�d beckgraund ch�cks� <br />Sig�ature Ta�te �-�f � � ' ! "i <br />Pleas� peinc �hi� farm �nd m�i3 nr taa�id-deliver nlong �x�ith g certitied copy of $ diplor�a ar cer�ificat� o��du��ian <br />ftt�rn a�chool af ma5;3sg� th�.r�py ins ludit�g proof of $ rr�ini��tum of �iO4 hotu's in su���ssfi►tly compl�t� c[s'cu'se <br />wQric as des�rib�d in .ttaseville Ordinance 115, tv(�ssa�e Thetapy E,�t�blishrrtenk�. <br />Y,icense �ee is �ipG,�10 <br />Make che�ks �ayabte to: Cit� af'I�os�v[lle <br />{„b:a�ed Zt��i���5LS9�al :�u�,�� I6� ��� �ti6Z-S�-ddd <br />�;�:��nd G��]��6�TS9�al :u�o.a� ���c� t�ti�i�-�ti-J,k1L.l <br />