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Finance Depa men'„ License Division <br />2660 Civic Center riv ` Roseville, MN 55113 <br />(65 Il 79 �I 7036 <br />,�New License ❑ Renewal <br />1. Full Legal Name (Please Print) <br />2. Home Address <br />(Street) <br />3. Telephone <br />4. Date Of B11'th (mm/dd/yyyy)_ <br />5. Email Address <br />6. Driver's License Numbe� <br />Massage Therapist License <br />C'/Nn, �,�rs <br />!T oot\ <br />For the License Year Ending June 30, ,1,1 i l,(� <br />..J �/7 � �f^y'/ �i <br />/F;,-crl <br />(City) (State) <br />❑ Home ❑ Work <br />(MirIN1Pl <br />(Z�P) <br />State of Issuance =�v''�� <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 />/�/�Gv /�i'��cj � /����C 4 � �'�:S.S �t `�? 1`1�.iC 1� ce ���—� � � ��c �f a-. li' ( c v. �•_��� ��� �� �'a <br />�_��� �. .I l�, v� .�� s�` (13 <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />.�Yes /3/��.Nl � ���G �I � 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 � o ❑ 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, wi11 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 priar 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 Rosevilie Police Department to run <br />your information for the required background checks. (Note: Back�round checks may take up to 30 days to complete.) <br />� ' � J � ._ <br />Signature ,e,'�v� �.�G "�t-�z �� ^--- Date � _�� Ar� <br />Please print t ts form and mail or hand-deliver along with a certified copy of a diploma or certificate of graduation fi•om a <br />school of massage therapy including proof of a minimum of 600 hours in successfully completed course work as described in <br />Roseville Oi•dinance 116, Massage Therapy Establishments. <br />License Fee is $100.00 (prorated quarterly) <br />Make checks payable to: City of Roseville <br />