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Attachment A <br />1���� <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651)792-7036 <br />Massage Therapist License <br />❑ New License � Rene�val For the License Year Endin� June 30, �-S <br />1. Full Legal Name (Please Print) 1 C' �; S �� �i �7 �f;�!�_,r }� � f; ��,� <br />2. Home Address <br />( Street) <br />3. Telephone . <br />4. Date of Birth �n�,u fld yyyy) <br />�. Email Address <br />� <br />6. Driver's License Ninnber <br />7. Ethnicity: <br />8. Sex: <br />(Last) <br />� <br />�Cell <br />/ 1 , <br />/ '� / <br />(First) <br />(City) � (State) <br />❑ Home ❑ 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 />iddle) <br />(Z�p)' � <br />10. Name and address of the licensed Massage Therapy Establishmeut at which you expect to be employed: <br />���,�+� �wra��t���� �-M�,ss�.� aaGi ���;.���;.� A� � s��.�J� Ic��� <br />1 L Have you held any previous massage therapist licenses`? If yes, in which city were you licensed'? <br />� Yes �'`/�,( b.'` `^ � ❑ No <br />12. If you answered Yes to number i 1 above, were any previous massage therapist licenses revoked, suspended or not <br />renewed'? If yes, explain in detail on the back of this page. <br />❑ Yes �No ❑ N,'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 exception 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 backgro�ind checks. (Note: Backaround checks may take up to 30 davs to complete.) <br />Signature <br />Date�y <br />� <br />Please pri thi orm and mail or hand-deliver along with a certified copy of a diploma or certificate of graduation fi-om a <br />school f assaae therapy including proof of a minimum of 600 how•s in successfully completed course work as described in <br />Roseville Ordinance 116, Massage Therapy Establishments. <br />License Fee is �100.00 (prorated quarterly) <br />Make checks payable to: City of Roseville <br />