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�� „y . , . � :�, � Finance Department, License Divisiov 2660 Civic Center Drive, Roseville, MN 55113 (651) 792-7036 Massage Therapist License (Please Print Clearly) � New License ❑ Renewal For License Year Ending 7une 30, � f)1 i,a 1. PuU Legal Name (Please Print) YO � � C7 � K, (Last) 2. Home AddressT (Street) 3. Telephone � 4. D1te of Birth b 5. Drivec's License Number 6. Etluliciry: 7, Sex: 8. �mail Address �' � I�la V'a y� �. C'.C� (First) (Middle) (City) (State) � (Zip) _ [� Cell ❑ Home ❑ Worlc State of Issuance � � �( 4� Y1(� Cd �1r1 Gz. I L,� C._. �j Y�- 9. Have you ever used or been ]cnown by any name other than the legal uame given in number 1 above? ❑ Yes [� No If Yes, List each full name along with dates and places where used. 10. Naine a�1d address of the licensed Massage Therapy EstaUlishment at which you expect to Ue employed: � v� � L � � � s' �� ►� La,�.c. �v� �.,t,C `�-e.� � o � � t�;� U-i I 4-e� I�lr1 ��S I► 3 11. Flave you held any previous massage therapist licenses? If yes, in which city were you licensed� � Yes t�� 1 � I�� a— I�i �D �� ❑ No 12. If you answered Yes to number 11 above, were any previous mass�ge therapist licenses revoked, suspended ar not renewed? ❑ Yes � No ❑ N/A If yes, explain in detail on a separate page. By signing Uelow you certify that the above infarmation is correct and authorize the City of Rosevilla Police Depart�nent to run your information for the required Uackground checks. Signahrre ' �p � Date �-'"�S''�� 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 successfiilly completed course work as described in Roseville Ordinance 116, Massage Therapy �stablishments. Liceuse Fee is $100.00 Make checics payable to: City of Roseville