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[�� _ +��—�� <br />�� ���_� <br />:��3 . 1 � ;���� <br />Fivance Department, License Division <br />2660 Civic Center Drive, Roseville, Mi�155113 <br />(651) 792-7036 <br />Massage Therapist License <br />� New License ❑ Renewal <br />1. Full Legal Name (Please Print) Thorson <br />(Last) <br />2. Home Address <br />(Street) <br />3. Telephone <br />4. Date of Birth (�nm/dd/yyyy) <br />5. Email Address <br />6. Drivei's License Number <br />7. Ethnicity: <br />8 <br />0 <br />Sex: <br />ror the License Year Ending June 30, 2016 <br />Tonia <br />(c��') <br />Lynn <br />(First) (Middle) <br />(State) (Zip) <br />� Cell ❑ Home ❑ Work <br />State of Issuance <br />Have you ever used or been laiown by any name other than the legal name given in number 1 above? <br />❑� Yes ❑ No Tf Yes, List each full name along with dates and places where used. <br />Tonia Lynn Dahlin (maiden name) 1958-1984 <br />10. \'ame and address of the 1 icensed Massage Therapy Establishment at which you expect to be employed: <br />Wellspring Massage Therapy (in Roseville Chiropractic Center office) 1935 County Rd B2, Suite 185 <br />11. Have you held aziy previous massage therapist licenses? If yes, in which city were you licensed'? <br />❑ Yes <br />� No <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 ❑ 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 />�ranted. 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 con-ect and authorize the City of Roseville Police Department to run <br />your information for the required background checks. (Note: Background checks maV take up to 30 davs to complete.) <br />� �,� r <br />n <br />S ignature � � G�.:� ; �,,� / ��,j�,�� Date `� `� ) �/ " / ' -� <br />� <br />Please pt�int 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 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 />