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��� <br />. � <br />Finance llepartment, License Division <br />2660 Civic Center Drive, Roseville, MN 551�3 <br />(65l) 792-7036 - <br />Massage Therapis� License <br />New License Renewal � <br />For License year ending June 30 �Q <br />I. Legal Name rfCi, f� f�l��/j � � i,L4'� <br />U <br />2. Home Address ���� c�Y!!y �� i <br />3. Home Telephane� � � � <br />0 <br />4. �aie of Sirth <br />5. Drivers License l��umber <br />6. Emaif Address A <br />� <br />/� <br />7. Have you ever used or 6een known by any name other than the legai name given in number 1 abave? <br />Yes _ ��o _ � If yes, ]ist ea�h name along wifh dates and piaces where used. <br />8. 1�fame and address of the licensed Massage Therapy Fstablishment tiiat you expect to be empioyed by. <br />4. Attach a ce��tified copy of a diplon�a or cert.ificate of graduation from a schnol of nlassage therapy <br />incl�ding a minin��m of 600 hours in successfu]]y completed course work as described in Rosevi]]e <br />Ordinance [ t6, massage `Fhera.py �stablishments. <br />lfl. Have you had any previous massage therapist �[ce.nse that �i�as revoked, suspended, or not renewed? <br />Yes Na _�___ if yes explain in detai�. <br />License Fee is 75.00 <br />A�Iaf�e checks payabfe to City of Roseville <br />