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� <br />�� � �I <br />Finance Department, License Division <br />2560 Civic Center Drive, R�sevi�ie, MN 551.13 <br />(651) 792-7034 <br />Nlassage "�`herapist I�icense <br />New License 1 RenewaI <br />--�°•'� � � <br />or L�censa year ending June 3Q , <br />Legal Name l.�-� U�t 5 e. ��,� �� <br />2. Home Address <br />3. Home Teleph.o <br />4. Date of Birth <br />5. Drivers Licens <br />6. Emarl Address <br />Attachment A <br />7. Have you ever used or been k.o by any nait�e other than the �egal name gi�en in n.umber 1 above? <br />Yes No � If yes, list each �atne along with dates and places wheee ased. <br />$. Nacne and address of the licensed Massage 7`herapy Establishment rhat you expect to be emp <br />`I� IM l °, � Q _ �2 �Q �--�1 �- 1 ?.1 n 4 � [? � �- L�� '�-t� �= ► n.� <br />9. Attach a certified copy of a diploma ar certifeate of graduation from a school af massage therapy <br />including a minimum oF 600 hours in successfully completed co�rse work as described in Rosevilie <br />Ordinance 116, massage '1'herapy Estabfish�nents. <br />l 0. Have yau had any previous age therapist license th.at was revoked, suspended, ar nat renewed? <br />Yes No � if yes exp[ain in detail. <br />License fee is '15.00 <br />Make checks payable to Gity of Roseville <br />