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� ��,� <br />��. <br />Finance Departrr�en�, License Division <br />2660 Civic Center Dr"t�e, Roseville, MN 551�3 <br />(f�51} 792-703b <br />Niassage 7Cherapist Ilicense <br />New License Renewaf � <br />For Licc�se yzar endi^v= June 30 <br />l. Legal Name___-�� �'3�N�-�� <br />2. Hon�e Address--- , _ , - . . . . , . . _ . _ - -- - � ._ <br />3. Home "Felephone <br />; <br />4, paze of Birth <br />�. Qrivers License Number t!� �• _ <br />G. En�ail Address <br />7. i-�ave yot� ever_ �sed or been kno�vn by any name other than the �ega] name giver� in number 1 above? <br />Yes _ � No fFyes, �ist each name along with dates and places �vhere used. <br />.�,.- <br />S. Na � an/d,,address of e/�icensed VIassage Thera�y Establishment that you expecC to be employed by. <br />„ l.�p�1 L.'Lh/Vti v� " <br />9. Attach a ceriified copy of a diploma or certiFicate of gr�iduation from a school of` massage therapy <br />includin� a minitnum oF600 hours i�i successFWly completed course wortc as descrrbed in Roseville <br />Ordinance 1 16, massage Therapy Establishments. <br />]0. Have you had any previous massage �herapist license that was revo€ced, stispended, or nof renewad? <br />Yes I�io if yes explain in detaal. <br />License fee is 7�.00 <br />ulake checks �ayable ta City of Roseville <br />