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��,� ,.� . , .� �,.� .� �f ., ...: �l, ..�1 �.t Finance Department, License Division 2660 Civic Center Drive, Roseville, MN 55113 (651) 792-7036 Massage Therapist License ,� New License ❑ Renewal /� /y For the Licens�'Year Ending June 30, r�l 4 1. Full Legal Name (Please Print) 2. Home Address _ ��ireet� 3. Telephone 4. Date Of BiPth (mm/dd/yyyy)_ 5. Email Address 6. Driver's License Number 7. Ethnicity: 8. Sex: ��.1 �yl �o �a�cl l� �l�l State of Issuance 9. Have you ever used or been lrnown by any name other than the legal name given in number 1 above? ❑ Yes U No If Yes, List each full name along with dates and places where used. 10. Name and address of the licensed Massage Therapy Establishment at which you expect to be einployed: 11. Have ou held a pre ious massage therapist licenses? If yes, in which city were you licensed? �S %��/..�- ❑ No 12. If you answered Yes to number 11 above, were any previous massage therapist licenses revolced, suspended or not renewed? If yes, ex�lain in detail on the back of this page. ❑ Yes ��o ❑ N/A The information that you are asked to provide on the application is classified by State law as either public, private or confidential. All data, with the exception of driver's license numbers, will constitute public record if and when the license is granted. Our intended use of the information is to perform the bacicground checic procedures required prior to license issuance, If you refuse to supply the information, the license application may not be processed. By signing below you certify that the above information is correct and authorize the City of Roseville Police Department to run your information for the re�uir background checks. (Note• Background checks mav take up to 30 da�s to complete.) Signature ( � � Date � Please print this form and mail or hand-deliver along with a certified copy of a diploma or certifcate of graduation from a school of massage therapy including proof of a minimum of 600 hours in successfully completed course worl< as described in Roseville Ordinance 116, Massage Therapy Establishments. License Fee is $100.00 (prorated quarterly) Malce checks payable to: City of Roseville