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���� <br />� <br />Finance Departiment, License Divisian <br />2664 Civic Center Drive, Roseville, MN 551�3 <br />(65l ) 79Z-7036 <br />1V�assage T'herapist License <br />New License Renewal �°� <br />For License year endin� June 30 `� <br />] . Legal \ame �` 4 � <br />,�, � _ � , , ., _ . . <br />2. Home Address ��`�� <br />� �, - <br />- _ � _ , _ i � . <br />3. Home� Telephone� <br />..� - .,-e,��—T-- <br />� i � <br />4. Date of Birth <br />— . � � , ,.. <br />5. Drivers E,icense Num' <br />_ ,� ._.. <br />6. Ei�iail Address <br />7. ]-iave yau ever used or been known by any name other tl�an the legal naine �iven in nwnber l above? <br />Yes No �__._ If yes, fist each name aEong with dates and places where used. <br />S. Name and address of the ]icensed <br />rn�ed hv_ <br />c � ����� <br />�. Attach a certifed copy of a diploma or certificate o1�;raduation froin a school of massage therap}' <br />including a minimum of 600 hours in successfully campleted course work as described in Rosevif[e <br />Ordinance 1 46, massage Therapy Establishments. <br />l0. Have you had any previous rnassage therapist license that was revoked, suspended, or not re��ewed? <br />Yes l�'o ry? e__ [f yes explain in delail. <br />License fee €s 75.00 <br />Make checks payable to City of Roseville <br />