Laserfiche WebLink
Rl� <br />i�� <br />Finance Department, License Division <br />2660 Civic Center Drive, 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, f� ��J <br />1. Full Legal Name (Please Print) �V '� �_Y� �����i <br />(Last) (First) (Middle) <br />2. Home Address � <br />(Street) <br />3. Telephone � <br />4. Date of Birth (mm/dd/yyyy) <br />5. Driver's License Number <br />6. Ethnicity: <br />7. Sex: <br />8. Email Address <br />❑ Cell <br />(City) � (State) <br />� Home ❑ Work <br />(Zip) <br />State of Issuance� <br />9. Have you ever used or been known by any name other than the legal name glven in number 1 above? <br />❑ Yes [�No 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 employed: <br />1i1(\SSG(tP i� i��v� � t�(�. C�i �6 ��'.�Ylil�i�; %�'V� l� ���C.:�U� �i� <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />❑ Yes �No <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, suspended or <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 information is correct and authorize the City of Roseville Police <br />Department to n your information for th _r,gquired background c}hecks. <br />� ' I <br />J �' � ���� ` / <br />Signature Date �jO � <br />� <br />Please prin this form and mail or hand-d�ver along with a certified copy of a dip(oma or certifi te of gr duation <br />from a school of massage therapy including proof of a minimum of 600 hours in successfully completed course <br />work as described in Roseville Ordinance 116, Massage Therapy Establishments. <br />License Fee is $100.00 <br />Make checks payable to: City of Roseville <br />����3 <br />