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_ ���.�L � � � i J i i f .L <br />� � - - <br />�i���e� Dep�rt���t, Lieeuse I�ivisi�n <br />2660 C�a� ���ter D�i�a�, Rosevilte, MN �S� �� <br />(��Y) 732--7036 <br />Massa�e �'herapist Licens� <br />❑ I�Ie�v License [�ItenewaI <br />I. �uli Legal i�ame (i'iease Print) <br />�. �ome Address <br />(strzst) <br />3. 'i'elephane �--- <br />4. Date ofBirtiz {��,/dd��yyy)� <br />S. Email Address <br />S. I3river's License Numbex <br />T. E4hnacity: <br />8. Sex: <br />��Cefl <br />- . �� <br />For the License Year Ending June 3U, ��, � <br />� , it . . /'t� I _�� <br />(FisStj fl �1 . , e <br />_ , . _, , <br />(City} (State) <br />0 �-Iome ❑ Work <br />State of Issuanc� <br />9. Haye you ever �sed or been knawn by any name other than the Iegal name given in number 1 abov�? <br />[] i'es (� 2�3o IfYes, List each �'ia�i narne along with da�es az�d places vvhere u�ed. <br />iU. 1lame and ac�dress of the 3icensed Nlassage T�ei�py �,stablishment at whi�12 you expect to be <br />M�.�erarAr �r,: n� ��rs7 I ok�,n�,�-� �vc �l, (�r�� ��� lt� , J <br />11. HaVe you held any previpus massa,ge therapist licenses? Ifyes, in which city were you licensed? <br />� Yes .�0��__ C] �o <br />(�rliddle) <br />_ ,. _ .. <br />(Zip) <br />2?. �f ys�u asaswen�i �'es to nt�mber 11 a.b�vs, �*cere any grevic�aas massag�.therapisi licea�ses revok�d,.suspended or n�st <br />renewed? If yes, expiain in detail an the back af ih�s p�ge. <br />[� 'Yes ❑ P3o [� i�i/A ��ivCc.,�.1 ��� t��" �"�-.-li �� CS�� GS� �i� � ��� <br />The infcirmaCion that you are asked to provide on the ap�licaiio� is classifed by State law as either public, private or <br />confidentiai. Ait data, with the exception of driver's iicense nian6ers, vvili cai�stitute public record if and when the Iicense is <br />granted. Onr iniended uss of the ini'oranation is to perforin the background chsck pracedures required prior to license issuance. <br />ifyou refvse to supply #l�e infarmation, the iicense applicatit�a� may not b� processed. <br />By sigping beiow you ceriify that the above informat�on is,correct and authorize the City of Rosevilte Poiice Dep�rtment ta run <br />your information for the required ba�kground checks. (No#e: Backeraund checks may take up to 30 days to comnlete.) <br />Date�� ��� <br />Please print this form and ta�ail ar hand-deIiver along with a certified copy of a diploma or certificate of graduation from a <br />scl�anl of massage therapy including proaf of a minimum of 600 hour� in successfully coanpleied course vvork as d�s�ribed in <br />Roseviile tJrdinance 116, ATassa,�e T�erapy Establishments. <br />License Fee is �100.40 (pror�ted quarterly) <br />Make ch+ecks payable to: Ciiy ofi' Roseville <br />