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��� � <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 ❑ Renewal �or the License Year Ending June 30, � <br />1. Full Legal Name (Please Print) �� <br />_ ^,�Last) <br />2. Home Address � <br />(Street) � � <br />3. Telephone . [� Cell <br />4. Date of Bitrth (m,»/dd/yyyy) <br />5. Email Address <br />— �- - — <br />6. Driver's License Number <br />7. Ethnicity: <br />8. Sex: <br />� (City)� (State) (Zip) <br />❑ Home ❑ Work <br />State of Issuance <br />9. Have you ever used or been kno�vn 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 />_ - -- 1 F 1_ �—�1 . �_• _ 1 _ ._ � <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be em <br />a�s� ��� � I G7 ex- �.�o� <br />I 1. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />❑ Yes �No <br />�I�: <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, suspended or not <br />renewed? If yes, ezplain 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 b}� State la�v as either public, private or <br />confidential. All data, with the exception of driver's license numbers, will constitute public recard if aud 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 background checks. (Note: Backaround checks mav take up to 30 days to com�lete.) <br />Signature I/ vC Date �� i—�� <br />Please print this form and mail or hand-deliver along with 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 �vork as described in <br />Roseville Ordinance I 16, Massage Therapy Establishments. <br />License Fee is $100.00 (prorated quarterly) <br />Make checks payable to: City of Roseville <br />