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��� : <br />�� : <br />.,��:�� J � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />(Please Print Clearly) <br />`�.New License ❑ Renewal <br />For License Year Ending June 30, �� <br />1. Full Legal Name (Please Print) W� �� <br />2. Home Addre� <br />3. Telephone <br />4. Date of Birth (mm/dd/yyyy)_ <br />5. Driver's License Numbe <br />6. Ethnicity: <br />7. Sex: <br />8. Email Address <br />9. Have you ever used or been lrnown 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 />�� .��,1��,r,�-, � r_ v�-�r-� � c�1A n r'�� C�Y� <br />10. Name and ad ress of the licensed Massage Therapy Establishment at which you expect to be employed: <br />�' JUY'�Qis . �� Q.� Z � rJ ��'O►i'Yl� 1 t� 1TV L� <br />� IZ,o�.v i���e., MN �� 1 t 3 <br />1 l. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />`�. Yes �Yi�( e �Y' OYG ► W D�Gi�OI.t,YU i ❑ No <br />s-E--Pa�.�Q , Sl�,o� <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, suspended or <br />not renewed? <br />❑ Yes �No ❑ N/A <br />If yes, e�lain in detail on a separate page. <br />By signing below you certify that the above information is conect and authorize the City of Roseville Police <br />Deparlment to run your information for the required background checks. <br />Signature <br />Date ' ! L� " ! <br />Please print��f�nail or hand-deliver along with a certified copy of a diploma or certificate of graduation <br />from a school of massage therapy including proof of a muumum of 600 hours in successfully completed course <br />work as described in Roseville Ordinance 116, Massage Therapy Establisiunents. <br />License Fee is $100.00 <br />Make checks payable to: City of Roseville <br />• �i�'e <br />112 <br />