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�`� <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55ll3 <br />(651} 792-7036 <br />Massage Therapist License <br />�..,/ � i <br />❑ New License �J,Renewal For the License Year Ending June 30, -�� t� <br />� �.� / / �� � �i <br />1. Full Legal Name (Please Print) <br />2. Home Address <br />(Street) <br />3. Telephone <br />4. Date ofBirth (mn,�dcUyyyy)_ <br />��/Ti �t_ //�l'IdT% N <br />(Last) (First) <br />(City) (State) <br />�Cell ❑ Home ❑ Work <br />/ <br />, , , . <br />5. Email Address <br />_,_� <br />6. Driver's License Number <br />— �` . _ . . , <br />7. Ethnicity: <br />8. Sex: <br />(Middle) <br />State of Issuance �' <br />9. Have you ever used or been known by any name otner tnan tne legai name g�vem m �umner � anove r <br />❑ Yes �No if Yes, List each full name along with dates and places where used. <br />/ <br />10. Na.me and address of the licensed <br />at which you expect to,�be employed: <br />(Zip) <br />ss i(� <br />11. Have you he ny pre ious massage therapist licenses? Tf yes, in which city were you licensed? <br />Yes � ��;/� �� S � /�� ❑ No <br />� <br />12. If you answered Yes to number 11 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 �f No ❑ N/A <br />/ _. <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 infoiYnation 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• Background checks may take up to 30 davs to complete.) <br />Date � `�D/ <br />Please print this form and mail or hand-deliver along �vith a certified copy of a diploma or certificate of graduation from a <br />school of massage therapy including proof of a minimum of 600 hours 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 />