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2015_0914_CCpacket
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2015_0914_CCpacket
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``;� <br />�.� <br />Finance De <br />t, License Division <br />2660 Civic Cent Dr e, Roseville, MN 55113 <br />( 1) 2-7036 <br />� <br />Massage Therapist License <br />❑ New License p Renewal <br />For the License Year Ending June 30, �C.� /(�� <br />l. Full Legal Name (Please Print) �v ��> i-�- L�.1 ��� CI� ���-� t� ��` �!:- i��� <br />(Last) (First) (Middle) <br />2. Home Address <br />(Streetl <br />3. Telephone <br />4. Date of Birth �t„�„lddly}�y-y)_ <br />5. Email Address <br />6. Driver's License Number <br />���n-> <br />�j. Cell ❑ Home <br />(StaYe) (Zip) <br />� Work <br />State of Issuance (�� 6`1 <br />9. Have you ever used or been known by any name other than the legal name given in number I above? <br />�Yes ❑ No If Yes, List each full name along with dates and places where used. <br />f'Vi /� f i'� G i� �; �`v�L t—� c� 1� I� G_ �`�"b2 L-�: i�- L. [� G r«� j�=�_ <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />�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.� � <br />���Sc--�.���, � � ��.l1'� <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />[�%Yes }-'.c; 5 �. � ; ���- <br />■ . <br />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 <br />renewed? If yes, explain in detail on the back of this �age. <br />❑ Yes .� No ❑ N/A <br />The information that you are asked to pr•ovide on the application is classified by State law as either public, private or <br />confidential. All data, with tlle exception of driver's license n�imbers, 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 prior to license issuance. <br />If you refuse to supply the infoimation, the license application may not be processed. <br />By signing below you certify that the above information is coirect and authorize the City of Roseville Police Department to run <br />your information for the requii•ed background checks. (Note: Back�round checks may take up to 30 days to complete.) <br />Signature � � � .� - � � �Ct`•�`" Date�2,l,��a�f /�� �G��_S <br />Please pt•int 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 Ordinance 116, Massage Therapy Establishments. <br />License Fee is �100.00 (prorated quarterly) <br />Make checks payable to: City of Roseville <br />
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