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1����� <br />� <br />Finance Department, License Division <br />2�i60 Civic Center Drive, Rasevilie, MN 55113 <br />(bS�) 792-7436 <br />Massage Therapist �icen�e <br />- w..���.�,.,� <br />__ <br />New License �. Renewai <br />�'or License year ending Jun.e 3Q �� <br />� <br />1. Lega1 Name �N °� �� <br />2. Flome A.ddress <br />3. Home Talephone . . <br />4, Date of B3rth , ._ <br />5. Drivers License Number <br />b. �mail Address <br />7. Have you ever used or been krrown by any name other than the kegal iaatne �iven in number l abave? <br />Yes No ��_ ]f yes, list each name along with dates and places wl�ere used. <br />�3. Nan�e and aticir s f Eile iic sed Massage Therapy �stablishi �ent [hat you ex ect ta be e�picyed b. <br />� � r�n�� ���-�r � ��a 2 ���� � s � ��N ss�l 3 <br />��. Attacl� a certifed copy flf a d'iploma ar certificate of �raduati.oi� From a schooi of massage therapy <br />inc{uding a minimwn af 6Q0 hours in saccessfully completed course wo1�k as described in Reseville <br />Ordinance 1 16, massage Therapy Establishments. <br />l Q, I-(a�e you had any previous massage therapist Eicense that was revaked, suspended, or nat renewed? <br />Yes No T� If yes explain in detail. <br />License fee is 75.Q0 <br />Make ehecks payable to City of Rosevi][e <br />\ <br />� <br />