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�f� , � . ,,. w,..�".,' ...�1� �4 <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 <br />1. Full Legal Name (Please Print) Buda <br />2. Home Address <br />(Sh�eet) <br />3. Telephone ( ,� <br />4. Date ofBirth (�nm/dd/yyyy; <br />5. Email Address � <br />6. Driver's License Number <br />7. Ethnicity: <br />8. Sex: <br />(Last) <br />�❑ Cell <br />For the License Year Ending June 30, 2015 <br />Elizabeth Louise <br />(First) (Middle) <br />(City) <br />❑ Home <br />(State) (Zip) <br />❑ Work <br />State of Issuance M N <br />9. Have you ever used or been known by auy 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 />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />inside mind & body Chiropractic Valerie Headrick %'� u ( � �,;j� �.� v.i y � , �����(� ��J, S� �Q � <br />, <br />11. Have you held any previous lnassage therapist licenses? If yes, in which city were you licensed? <br />�■ Yes Woodbury MN <br />❑ No <br />12. If you answered Yes to nuinber 11 above, were any previous massage therapist licenses revolced, suspended or not <br />renewed? If yes, explain in detail on the back of this page. <br />0 Yes ❑ No ❑ N/A <br />The information that you are asked to provide on the application is classified by State law as either puUlic, pcivate or <br />confidential. All data, witli the exception of driver's license numbers, will constitute public record if and when tl�e licei�se is <br />granted. Our intended use of the infoi•mation is to perform the background check procedures required prior to license issuance. <br />If you refuse to supply the information, the license application n7ay not be processed. <br />By signing Uelow you certify that the above information is coi�rect and autho�•ize the City of Roseville Police Department to run <br />yout• information for the required background checks. (Note: Background checks mav take up to 30 davs to complete.) <br />_'":'� ��� ,�� �� ��--.. <br />Date �3/27/2015 <br />Signature / ,, ; ,� <br />/ _. <br />Please print this form and ��id or haud-deliver along with a cei�tified copy of a diploma or certificate of graduation from a <br />school of massage therapy including proof of a minimuin of 600 hours in successfully completed course worlc as described in <br />Roseville Ordinance ] 16, Massage Therapy Establishments. <br />License Fee is $100.00 (prorated quarterly) <br />Malce checics payable to: City of Roseville <br />