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�"� <br />�� <br />Finance Departmenf, License Division. <br />2660 Civic Center Drive, Roseville, MN 551�3 <br />(6Si) 792-7036 <br />Il�Iassage T"�erapist �ieense <br />New License Renewat V 1� <br />For License year endin Juna 30 �� <br />1. Legal Name 'L.i ! ��I� ��� I � � <br />� i <br />2. Home Address <br />� _ _ , <br />3. Home Telephone <br />4. Date of Birtf� <br />5. Drivers License. Number <br />� <br />5. �mai! Address <br />:_..�_. L� <br />7. Have you ever used ar b en know� by any name other than the legal name giver� in number 1 above? <br />Yes o If yes, IESt each name aiong with dates and places where used. <br />&. Name and addr�ss of <br />�xpect to,pe �mp�oyyc}C � jl� <br />� i�G�S'C'U f / <br />9. Attach a certified copy of a diploma or certificate o#'graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course work as described in Rose�ilEe <br />�rdinance 1� 6, massage Ti�erapy Establishments. <br />t 0. Have you �ad any pre ' assage iherapist license that was revoked, suspended, or not renewed? <br />Yes o If yes explain in detaii, <br />License fee is 75.00 <br />MaEce checks payable to City of Raseville <br />