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r <br />, <br />e <br />� , e,� . � _ �.�i�.� _ � <br />�� <br />Finance Department, License Division <br />2660 Civic Center Driv,e, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />(Please Print Clearly) <br />� New License ❑ Renewal <br />For License Year Ending June 30, � ��.Q <br />1. Full Legal Name (Please Print) �� ���,�� � i 1�l.�� � I��C�-� J'�--� <br />(Lastl (Firstl (Middlel <br />2. Home Address <br />(Street) <br />3. Telepl�one _ <br />4. Date of Birth (mm/dd/yyyy)_ <br />5. Driver's License Number � <br />6. Ethniciry: <br />7. Sex: <br />a <br />8. Email Address <br />(City) (State) <br />�Cell �Home ,�Work <br />(Zip) 4 � <br />State of Issuance �`��" � <br />9. Haye�+you ever used or been known 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 />�r��-i �.' � �.�-�`��'1 ��� �, �I � � �� ��' <br />10. Name and address of the licensed Massage Therapy Establishment at whicll you expect to be employed: ; <br />�'��- � ��- e�.l � V� v � '� ' (.��1 ��, � -�� t��.1 ' <br />11. Have you ld any prev� s massage t ? If yes, in wl�ich ciry were you licensed? C~�� ��� �� �' <br />j�Yes �'1 � No ���� � , � ' <br />, ,� � <br />12. If you answered Yes to number 11 abov�e,��w �a1ry previons�m�assage t�erapist licenses revoked, suspended or � g�� <br />not renewed? <br />❑ Yes �No ❑ N/A <br />If yes, explain in detail on a separate page. _ <br />By signing below you certify that the above <br />Department to run your infoymation for th <br />Signature <br />Please print tl�is fc <br />from a school, of n <br />work as described <br />ion is correct and authorize the City of Roseville Police <br />backgrowld checks. <br />Date � � � � �! <br />r along with a certified copy of a diploma or certi�cate of graduation <br />proof of a ininimum of 600 hours in successfully completed com•se <br />116, Massage Therapy Establishments. <br />License Fee is $100.00 <br />Make checks payable to: City of Roseville <br />