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�d� <br />��� . J ' _ .....,r� <br />,...,,. .—� �, - � � — . <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />� New License ❑ Renewal For the License Year Ending June 30, � d�,/ <br />1. Full Legal Name (Please Print) \( lJ�, �� a� �1 <br />(Last) (First) (Middle) <br />2. Home Address <br />(Street) <br />3. Telephone �_� . _ <br />4. Date Of Birth (mm/dd/yyyy)_ <br />5. Email Address <br />6. Driver's License Number <br />7. Ethnicity: <br />8, Sex: <br />� <br />— �i <br />— _ _ _ • � �CitS') � <br />_ [�. Cell ❑ Home <br />(State) (Zip) � <br />❑ Work <br />State of Issuance <br />9. Have you ever used or been lrnown by any name ather than the legal name given in number 1 above? <br />❑ Yes � No lf Yes, List each full name along with dates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishinent at which you expect to be employed: <br />I—If�(� iv►n��raf�A . l��l I��ro �-4 �c�ec��lill� ��all� <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />[�, Yes � � A 1��, �� � ❑ No <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, 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 check 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• Background checks may tal<e up to 30 days to complete.) <br />1 <br />Signature � Date �6 �� i�"` �� <br />Please print t is orm 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 />0 <br />License Fee is.��6�. (prorated quarterly) <br />Make checics payable to: City of Roseville <br />