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Attachment A <br />��� � <br />Finance Depar�menf, License Division <br />2660 Civic Cenfer Drive, Roseville, MN 551�3 <br />(651 } 792-7034 <br />Massage T'herapist License <br />New License �� (� RenewaE <br />For License year ending June 3Q <br />l. Legal Name ��(��f�, ��j <br />2. Hame Address <br />3. Home Telephone_ <br />4. Date of Birth <br />r• <br />5. Drivers License Number <br />6. Email Address <br />7. Have you ever used ar been !cn by any name other than the Iega] name given in number 1 abo<<e? <br />Yes 7�10 �___ If yes, �ist each name along with dates and places where used. <br />8. NarrEe and address. of the ]icensed Massage Therapy Esta lishment that you expect, to be en�ployed by. <br />�—Y l� ����4 ^ �2� ��,�1.aj � ��_ . 1 E (�' _��_�11� <br />9. Attach a certified capy of a di�lotna or certificate of graduation from a schoo[ of massage tE�erapy <br />including a minimum af CDp hours in successfully completed course work as described in l�osevil[e <br />Qrdinance i]6, massage 1'herapy Estab]ishments. <br />14. Have you had any previous ssage therapist [icense that was revok.ed, sus�ended, or not renewed? <br />Yes No If yes explain in detai[. <br />License fee is 75A0 <br />MaEce cf�ecks payable to City of Rosevifle <br />