Laserfiche WebLink
��..�. -� ., �:��� <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-703G <br />� New License ❑ Renewal <br />1. Full Legal Name (Please Print) <br />2. Home Address _ <br />3. Telephone <br />4. Date ofBirth (mm/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, �D 1 l� <br />�-. � CJ� �l � � I � �i <br />(Last) � (First) (Middle) <br />State of Issuance <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 />��;inl Drr�n,:,sn M�cc c1 G1l� . !t� '�.f:��/l �i !�' C�.Plvl f't"/!', �v\c'rts� 1 l�.`�w.�3 �� <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />�-Yes `�bS�/�ii 1.l � ❑ No <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revolced, 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 aslced to provide on the application is classified by State law as either public, private or <br />confdential. 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 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: Background checks may talce up to 30 davs to complete.) <br />S� <br />Signature -�i � � Date,� E.� '� . �` <br />Please print this form and mail or hand� iver along with a certified copy of a diploma or certificate of graduation from a <br />school of inassage therapy including proof of a minimum of 600 hours in successfully completed course worlc as described in <br />Roseville Ordinance 116, Massage Therapy Establishments. <br />License Fee is $100.00 (prorated quarterly) <br />Malce checks payable to: City of Roseville <br />