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��►�'�� ��- ,� -�� ��,� <br />� �"�"�"'�.�+ • � � � i""�"i :� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />❑ New License `IZenewal For the License Year Ending June 30, l�"� � <br />� <br />1. Full Legal Name (Please Print) $�/� �11 �-�� �n ���'� � ��� �' �1 1) u s� ��,u t 1 <br />(Last) (First) (Middle) <br />. _ .a-..,— . . <br />2. Home Address _ <br />(Street) <br />3. Telephone �,�___ <br />4. Date of Birth (mm/dd/yyyy)_� <br />5. Email Address <br />1 � <br />6. Driver's License Number _ <br />7. �thnicity: <br />8. Sex: <br />(City) <br />�Cell ❑ Home <br />" F/ \ <br />(State) (Zip) <br />❑ Work <br />State of Issuance j�/�� <br />9. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />❑ Yes �'o- 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 empioyed: <br />�L, 4 "1 �.. i x � � � c�>� �, �i � .1� `%�Zl ��Q..�"1 '� ���'�7Go l __ <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />�,�Yes �/ tIi t1�d1 Vt ❑ No <br />� <br />I2. Tf you answered Yes to numner 11 above, were any previous massdge therapist licenses c°evolced, 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 />granted. Our intended use of the information is to perform the background checic 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 correct and authorize the City of Roseville Police Department to run <br />your information for the required background checks. (Note• Bacicground checks ma,�talce up to 30 days to complete.) <br />.�-, , , <br />„ <br />Date � � L' <br />Please priri'�his�rm and (l�il 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 ll6, Massage Therapy Establishinents. <br />License Fee is $100.00 (prorated quarterly) <br />Malce checks payable to: City of Roseville <br />