Laserfiche WebLink
���'��� ~1 1� 4 ' �•���� <br />► _,.....,.,,1 , ,_„p.,�,�, �...� � 1 <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />❑ New Ilicense ❑ Renewal <br />1. Full Legal Name (Please Print) <br />2. Home Address <br />(Streetl` <br />3. Telephone i <br />4. Date ofBirth (m�n/dd/yyyy)� <br />5. Email Address <br />6. Driver's License Number <br />7. Ethnicity: <br />8. Sex: <br />Massage Therapist License <br />For the License Year Ending June 30, :�C) %S` <br />�. �V ,�i � <br />(Last) (First) <br />�( ity) (State) <br />[�Cell ❑ Home ❑ Work <br />[ <br />State of Issuance <br />9. Have you ever used or been lrnown 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 />� <br />(Middle) <br />(Zip) <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />��f� � i'C. �� � �"�'d'tc� •{� ���,�tr�t 1�� /�'� Zi� . Fj'�-.�a t'�� f-1 Gl� t� ,�ir� S`:S�i� r' t� <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />� Yes ��a-d'�$�d PY � ❑ 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 pa�e. <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 ]icense 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 th� require background checks. (Note: Bac�round checks mav take up to 30 davs to complete.) <br />/ ,' , <br />Signature r ` �—�- � -----_� Date� / � /'C <br />Please p int th'-s�form and mail or hand-deliver along with a certified copy of a diploma or certificate of graduation from a <br />school o�m ssage therapy including proof of a minimum af 600 hours in successfully completed course work as described in <br />Roseville Ordinance 116, Massage Therapy Establishments. <br />�G>� <br />License Fee is ��B:�fl (prorated quarterly) <br />Make checics payable to: City of Roseville <br />