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��;,1 ��1��/ y 1���ifJ� <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />dNew License ❑ Renewal <br />�l. Pull Legal Name (Please Print) �U��UI�-� <br />(Last) <br />2. Home Address _ <br />(Street) <br />3. Telephone 1 _. <br />4. Date of Birth (mm/dd/yyyy)_ <br />5. Email Address <br />— 1 <br />6. Driver's License Number <br />7. Ethnicity: <br />8. Sex: <br />T�Cell <br />m <br />For the License Year Ending June 30, �o �'� <br />� �./�. <br />(First) <br />(City) (State) <br />❑ Home ❑ Work <br />State of Issuance_ <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 />�v. <br />(Middle) <br />r_ <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />� I r� <br />,�`.e:i"Yl� ��ri� .,. �_ `�' � l �vvuLv�CS � � 2vS�.v`�� Z � a� ��YI�L�Y�' �i� �� l� �� �c �4^ � <br />p� L``� � ` <br />��� �,��`��, I 1. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />�,Yes ��L�rJ ❑ No <br />(Zip) <br />12. ii you answered Yes to number 11 above, were any previous massage therapisi 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 />� <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 nwnbers, will constitute public record if and when the license is <br />granted. Our intended use of the information is to perform the background check procedures required prior to license issuance. <br />If you refuse to supply the infonnation, the license application may not be processed. <br />By signing below you certify that the above information is coirect and authorize the City of Roseville Police Department to run <br />your information for the required background checks. (Note: Backeround checks ma ty ake up to 30 days to complete.) <br />Signature � '��I� Date �� � � 2-�� `-I- <br />Please print is form and mail 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 116, Massage Therapy Establishments. � <br />License Fee is $100.00 (prorated quarterly) <br />Make checks payable to: City of Roseville <br />