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�� <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />�New License ❑ Renewal <br />1. Full Legal Name (Please Print) <br />2. Home Address <br />(�treet) <br />3. Telephone <br />4. Date ofBirth �mmiaa�yyyy) ' <br />5. Email Address <br />6. Driver's License Number <br />Massage Therapist License <br />For the License Year Ending June 30, � m/ <br />(T a etl ( <br />1�-11Y1 <br />�Cell ❑ Home <br />���aic� <br />❑ Work <br />(Middle) <br />\'�'Yl / � <br />State of Issuance C�_. <br />9. Ha�e 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 which city were you licensed? <br />�J Yes �ur/��� . ❑ 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 nuinbers, will constitufe 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• Back�round checks ma,�take up to 30 davs to complete.) <br />Signature �' Date (7���-��7A1� <br />Please print this 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 Ordinan.ce 116, Massage Therapy Establishments. <br />License Fee is $100.00 (prorated quarterly) <br />Make checks payable to: City of Roseville <br />