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��� <br />Finance De�artment, License Division <br />2660 Civic Center Drive, Roseville, MN 551�3 <br />(651)792-7036 ' <br />1Vlassage Therapisf License <br />New License Renewa] <br />For License year ending ]une .i� 1� <br />l . Le.gal l�ame �Ai �i�L �if��.� �t P��1..i\� �V }�L`��-� <br />.�.. � n _ .� - _ - <br />2. Ho�ne Address � <br />_, <br />3. i�onie Telephone ! <br />4. Date of Birth <br />5. Drivers License \?um6er <br />, _.. <br />G. �mail Addres <br />U � <br />- - ,___ _ 5! 13 <br />7. Have y��� ever used ar been ]�-^•��n hv any ��ame other than the ]ega] name �iven in number l above? <br />Yes No ��_ If yes, list each name along �i�ith dates and places where used. <br />8. Name and address of the licensed Massage Thera y Establishm t at �ou expect to be employed by. <br />�c�n�'�T'� �apy 1(�Z`� vJ�....1��`�_ t�a�v'tilk? M tv �5 i 13 <br />9. Attach a certified c.opy of a dip]oma or certificate of graduation from a school of massage therapy <br />including a n�inimunt of 600 hours in successfully completed course work as described in Rose.ville <br />Ordinance 1 I6, inassage Therapy Establishments. <br />l0. Ha��e you had any previous r assage t�erapist license that was revoked, suspended, or not rene�ved? <br />Yes I��o 7� If ye.s explain in detail. <br />License fee is 75.Q0 <br />Make checks payable to City of Rosevi�le <br />