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��� ..� . e . r <br />� <br />� <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, ��.�.',��7 �. � �.�� <br />1. Full Legal Name (Please Print) <br />2. Home Address_ <br />3. Telephone � <br />'" (Last) <br />(Street)� <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 />(' � irst� <br />_A 1J�n A . <br />� (City) (State) <br />�Cell ❑ Home ❑ Work <br />(Middle) <br />y (Zip) ° <br />State of Issuance-- �f �OT�\/ <br />9. Have 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 />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />11. Have you held any previous massage therapist licenses? If yes, in whi�ah 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 run your information for the required background checics. <br />Signature �) � l t w'T brt. �"�`�' Date 2 S� <br />Please print this form and mail or hand-deliver along with a certified copy of a diploma or certificate of graduation <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 />