Laserfiche WebLink
��� : � .� � _��� <br />��' .� �_ <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist License <br />�ew License ❑ Renewal Far the License Year Ending June 30, '�l �' <br />1. Full Legal Name (Please Print) �i�� ��' �i � � �� `j'� � J �l (�1 (�,�,� <br />��*� rF�.�+� rn�r;,a,aiP� <br />2. Home Address <br />��ireet� <br />3. Telephonf <br />4. Date of B1Pth (mm/dd/yyyy; <br />5. Email Address <br />6. Driver's License Number <br />7. Ethnicity: <br />8: Sex: <br />l�1tY1 l�tateJ (�lp) <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 />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be einployed: <br />� � ,� .i ��� C. � 't1(.� � E.. � '�7 �"l l..c _�� i r�.��t'�—, � � v�.e.. � (Lc� ��v� � t..�._ 'V `� ,/�J �`�"�ll � <br />11. Have you held any previous massage therapist licenses? If yes, in which city were you licensed? <br />�J Yes �_� i� l'�- � V � �,.�iV ��to <br />12. If you answered Yes to number 11 above, were any previous massage therapist licenses revoked, 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 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 tk�atjthe 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 checks ma, ty ake up to 30 davs to complete.) <br />I <br />Date � � � �.. � � <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 i�icluding proof of a minimum of 600 hours in successfully completed course work as described in <br />Roseville Ordinance 116, Massage Therapy Establishments. �---� ,,,� <br />� � <br />License +-ee-is-$3��(prorated quarterly) <br />Make checics payable to: City of Roseville <br />