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``;� �.� Finance De t, License Division 2660 Civic Cent Dr e, Roseville, MN 55113 ( 1) 2-7036 � Massage Therapist License ❑ New License p Renewal For the License Year Ending June 30, �C.� /(�� l. Full Legal Name (Please Print) �v ��> i-�- L�.1 �� CI� ��-� t� ��` �!:- i�� (Last) (First) (Middle) 2. Home Address (Streetl 3. Telephone 4. Date of Birth �t„�„lddly}�y-y)_ 5. Email Address 6. Driver's License Number ��n-> �j. Cell ❑ Home (StaYe) (Zip) � Work State of Issuance (�� 6`1 9. Have you ever used or been known by any name other than the legal name given in number I above? �Yes ❑ No If Yes, List each full name along with dates and places where used. f'Vi /� f i'� G i� �; �`v�L t—� c� 1� I� G_ �`�"b2 L-�: i�- L. [� G r«� j�=�_ 10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: �y C_i�12 ��r �'�1�' K � l3 t:• t� �/ Ih; G t�� lC f �� il� C: �Lt � l�� ,�1ti. u� p � 2 � i` 1`z �- l L� f r r��;'�SU �ti f��' � tV� . S.o� f f_- ( c.� � ��Sc--�.��, � � ��.l1'� 11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? [�%Yes }-'.c; 5 �. � ; ��- ■ . 1[�',. If j'Oil uiSSW2i�u i��S t0 i�lilii�"i:.i 1 i flriG'vc� W�ic a7'y' �i'c^WiGiiS iiluJ5u�2 iii2t'a�7iSi ii:.ciiSeS iGvO�CC�i� SUSp�tiC�Q Oi i�Gi renewed? If yes, explain in detail on the back of this �age. ❑ Yes .� No ❑ N/A The information that you are asked to pr•ovide on the application is classified by State law as either public, private or confidential. All data, with tlle exception of driver's license n�imbers, wi11 constitute public record if and when the license is granted. Our intended use of the information is to perform the background check procedures required prior to license issuance. If you refuse to supply the infoimation, the license application may not be processed. By signing below you certify that the above information is coirect and authorize the City of Roseville Police Department to run your information for the requii•ed background checks. (Note: Back�round checks may take up to 30 days to complete.) Signature � � � .� - � � �Ct`•�`" Date�2,l,��a�f /�� G��_S Please pt•int this form and mail or hand-deliver along with a certified copy of a diploma or certificate of graduation from a school of massage therapy including proof of a minimum of 600 hours in successfully completed course work as described in Roseville Ordinance 116, Massage Therapy Establishments. License Fee is �100.00 (prorated quarterly) Make checks payable to: City of Roseville