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R1�`,/,� <br />— `.-,-s J <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />�New License ❑ Renewal <br />1. Full Lega1 Name (Please Print) <br />2. Home Address <br />3. Telephone � <br />4. Date of Birth pn,rvdcUyyyy� <br />�. Email Address <br />6. Driver's License Nimlber <br />7. Ethnicity: <br />8. Sex: <br />/71e�')�Z c �C�r; <br />(Last) <br />Foi• the License Year Ending June 30, �� ��� <br />� <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 emnl�veri• <br />; � 1 �� ;-r, r� ; � -t , ,.,, ,�, � ,� _. / _ s <br />���ll i <br />P� rn (<<�se�v�, Il�, �[ <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />�Yes_�(����)iYi`�UG�t��'. %�1�� <br />❑ 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, esplain in detail on the back of this page. <br />❑ Yes ❑ No [/� N/A <br />r <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, 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 con•ect and authorize the City of Roseville Police Department to run <br />your information for the required backgi•ound checks. (Note: Back�round checks ma take u to 30 da s to com lete.) <br />, <br />Signature � � <br />a,n v� �- Z� I <br />C �� Date % �i ~' �j �- <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 inctudin� proof of a miniminn of 600 houis in successfully completed course ��vork 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 />