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��'� �_ � �� , """�"�� ��: - - - _�..�: Finance Department, License Division 2660 Civic Center Drive, Roseville, MN 55113 (651) 792-7036 Massage Therapist License (Please Print Clearly) �New License ❑ Renewal For License Year Ending June 30, � bl� 1. Full Legal Name (Please Print) L�» � ��/V � (Last) (First) (Middle) 2. Home Address (Street) 3. Telephone _ 4. Date of Birth (mm/dd/yyyy)_ 5. Drivec's License Number 6. Ethnicity: 7. Sex: 8, Email Address Attachment A (City) (State) (Zip) �Cell ❑ Home ❑ Work State of Issuan.ce 9. Have you ever used or been known by any name other than the legal name given in number 1 above? ❑ Yes �No If Yes, List each full name along with dates and places where used, 10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: �1 ci��, �'%tsr�r�,� �33� LP.xihafaz, �Ve /I� 4?nsevil%o /Vi/1� .�'.$ ll. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? ❑ Yes [9�No �a � 12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, suspended or not renewed? ,�p ❑ Yes ❑ No 191J N/A If yes, explain in detail on a separate page. By signing below you certify that the above information is correct and authorize the City of Roseville Police Department to run your information for the required background checks. Signature ��,,� 1 ' Date ��z-1 ��o1-a' Please print this form and mail or hand-deliver along with a certified copy of a diploma or certificate of graduation from a school of massage therapy including proof of a minimum of 600 hours in successfully coinpleted course work as described in Roseville Ordinance 116, Massage Therapy Establishments. _-.-�_... License ee is $100.00 Make checks paya e to: City of Roseville