Laserfiche WebLink
R`�jwAI7��J r 1��� <br />` <br />Finance Department, License Uivision <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />� Neev License � Rene�a•al <br />I. Full Lcgal Namc (F'leasc Print) <br />2. Home Address <br />(StreeU <br />:3. Telephone � <br />4. Date of Birth n»n,�dcUyyyy�_ <br />,5. Email Address <br />fi. Driver's License Number___ <br />7. Llhnieity: <br />li�assage Therapist License <br />S�EIG S <br />( Last ) <br />/: <br />For the License Year Ending June 30, �2� �5 <br />�.►Di <br />(First) <br />(City) (State) <br />❑ Home ❑ Work <br />�Lr2F}��71� <br />(Middle) <br />(Zip) <br />State of Issuance � 1 fl rl E50^T�' <br />S. Scx: <br />9. Ha��e you ever use<i 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 datcs and places where used. <br />�t�1 �u2A-�3�"t'++ SC`t-fnEoD� L�.SEI��fL�oR �� �t.�z� %91�Jj <br />10. Name and address of the licenscel Massage Therapy Est�iblishment at which yuu expect to be employed: <br />�S��- o� Ts��ca,A�.;-��� �,�sSqE� -- 2��,, ���:�-w �v� � �� <br />�s�:v��: <�� �s r�3 . <br />1 1. Ha4e you held any previvus massa�;e thcrapist licenses? If yes, in which city were you licensed'? <br />� Ycs _,_ �__ _ L(�c ---- �it�-�J� � ry`------- ❑ No <br />��___-- _____--_ <br />12. If you answered Yes to number 1 l above, �vere any pre��ious massage therapist licenses revoked, suspended or not <br />renewed'? If yes, explain in detail on the back of this page. <br />❑ Yes (�J No ❑ N/A <br />The infonnation that you are asked to provide on the applicati<m is classified by State Isw as either public, private or <br />confidential. All data, �vith the exception of' driver's ►icense numbers, will constitute public record if and when the license is <br />grante<I. Our intende� use of the infoemati��n is to perform the background check prc�cedures required prior to license issuance. <br />If you refuse to suppty the informatian, the license application may not be processed. <br />By si;ning bel��w you certify that the above infornr,�tion is corcect an�l authorize the City of Roseville Police De�artment to run <br />your infonnation for the required backgroun<i checks. (Nnte: B.�cl:�,round checks m�take� te� 30 days to coit�letg.l <br />Date t'`t'Y �� 2-o I�j <br />Please print this form and mail or hand-deliver along with a certified copy of a diploma or certiticate of graduation from a <br />school of massage tkierapy including proof of a tnininium of' 600 liours in saccessfufly completed courve „�orh as described in <br />Roseville Ordinance I(6, Massage Therapy Establishments. <br />License Fee is $100.0(1 {prorated quarterly) <br />Make checks payabte to: City of Roseville <br />