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�°� .I <br />Finance Deparfinent, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(6S1) 792-7036 <br />Massage Therapist License <br />New License � Renewal <br />For License year ending June 30 c� <br />l . Legal A°ame �,R.�, � �A��LS� �i <br />2. Home Address — _ <br />3. Hnme Telephone <br />4. Date of Birth <br />S. Drivers License t��umber <br />6, E�l�ai! Address -, <br />� v <br />7. Have you ever used or been knawn by an}' name other ihan the legal name given ir� number 1 above? <br />yes �� No If yes, list each name along with dates and places where used. <br />$. Name and ad ress of the liceilsed Massa�e `Therapy Establishment that you �xpect to be en�ployed by. <br />��a.:� r�,�.,�v� , W�� 11 we55 �c�_�r� 1�l l�. � �2 <br />- �, :Y�`�t�� ��� { <br />9. Attach a certified copy of a diploma or certificate oi� graduatian from a schoo] o� massage therapy <br />including a minimum of 600 hours in successfully completed course wark as described in Roseville <br />Ordinance ] f 6, massage Therapy Establishrrients. <br />i0. Have you had any previaus massa,�e thera�ist license that was revoked, suspended, or not rene���ed? <br />Yes No � If yes explain in deiail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />