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��� ...,� ...� <br />�� <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 For the License Year Ending June 30, <br />1. Full Legal Name (Please Print) �Q99Q ��Iy1Q <br />T ..�.� � ,:..�.� �r,.:aa,_� <br />2. Home Addres: <br />3. Telephon� <br />4. Date of Birth (�mn/dd/yyyy)_ <br />5. Email Address <br />6. Driver's License Number <br />7. Ethnicity <br />8. Sex: <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 />�►_r�m�� �r sA�l ��. � (d�� ��`t<.1J_ .��i �, �v� �, .�� ���i� <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />� Yes ;�,��Vi 1�E ❑ No <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revol<ed, suspended or not <br />renewed? If yes, explain in detail on the back of this page. <br />❑ Yes j�j No ❑ N/A <br />The information that you are asked to provide on the application is classified by State law as aither 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 correct and authorize the City of Roseville Police Department to run <br />your information for the required background checks. (Note: Back�round checics mav talce up to 30 davs to complete.) <br />Signature Date I/ I J/�, _ <br />� <br />Please print this form an mail or hand-deliver along with a certified copy of a diploma or certiiicate 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 />Malce checks payable to: City of Roseville <br />