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��� � <br />1 <br />Finance DepartmenE, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />Massage Therapist L�cense <br />New Liccnse /\ Renewal <br />For L.icea�se year ending June 30 ��� _ <br />r} . , �- <br />] . Lcgal Name <br />, — . _. �l. „ <br />2. Home Address <br />3. Home Telephone ,� _ <br />4. Date of Birth <br />5. Drivers �,icense Number <br />6. Emai] Address�,_,___ � <br />r � _� . <br />V . <br />7. t�ave you ever used ar been known by any name other than the legal nan�e given in number 1 above? <br />Yes No � If yes, list each name along urich dafes and places ���here used. <br />S. Na��� ad�r�ss of the lic�se,��Mas� age Therapy Establishment t�at you expcct to be employed by. <br />_ G D t�Y� �r vt �!'i <br />9. Attach a certified copy of a diploma ar certificate of graduation fi�om a school of massage therapy <br />including a minimum of 660 hours in successfully completed course wark as describecf in Roseville <br />Ordinance I 16, massage Therapy �sta6lishmenis. <br />] 0. Have you had any prcvious massage therapist lrcense that was revoked, suspendcd, or not rene�ved? <br />Yes No ,x If yes cxplain in detail. <br />License fce is 75.00 <br />Make checks payahlc to City of Roseville <br />