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� �� ..� �� � Finance Department, License Division 2660 Civic Center Drive, Roseville, MN �5113 (651) 792-7036 ldx��sage Therapist License - (Please Print Clearly) � New License ❑ Renewal For License Year F,nding June 30, (,�-� I. Full Legal Nai�ne; (Please Print) (.�h�,,l li'�,�i �� i��'aV�t C.�.-�, ��'�' �T .� ctl lFirstl (Middle) 2. Home Address � � � -- (Street) 3. Telephone _ 4. Date of Birth (mm/dd/yyyy)_ 5. Driver's License Number 6. Ethnicity: 7. Sex: 8. Email Address ❑ Cell (City) (State) [� Home ❑ Work Skate of Issuance N1T1 (Zip) 9. Have you ever used or been known Uy any name other than tihe legal naine given in number 1 above? [� Yes ❑ No If Yes, List each full name al�ng with dates and places where used. Ro � t�. r l �.Irt_anc�� '� i�e.,�,r� i_ �vv u'v el �.v� ��,wi�.) f►��1 ��,� c� a l l��e.c�u°� b�e.�� r�� 1�. Name and addri,ss of the licensed Massage Therapy Establi ,hment at which you expect to be employed: MGSSU�e.. Gu��vu-j �2�5� �ai�v'I�w t4V� Sud�-�., �ac� '1Z,�S�.Vt1�•e.,, �✓I►�f i�°5t�� --- 11. Have you held a.ny previous massage therapist licenses? lf yes, in which ciry were you licensed? ❑ Yes � No 12. lf you answered Yes to number 11 above, were any previous massage therapist licenses revoked, suspended or not renewed? ❑ Yes �7 No � N/A �f yes, explain i.n detail on a separate page. By signing below you certify that the above iuformation is correct and authorize the City of Roseville Police Department to run }�our information for the required background �hecks. Signature V �`�"�-R-a— �-�'U`'`'�~ �' Date �S I �gi �� Please print this form and mail or hanc�-deliver along with a certified copy of a diploma or certi�cate of graduatiou from a school of mz�ssage therapy including proof of a minimum of 600 hours in successfully completed cotuse work as described in Roseville Ordinance 116, Massage Therapy Establishments. License Fee is $10[I.00 Make checks payalbl.e to: City of Raseville