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���� �w <br />.�•,,�► 1 . � J J� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, 117N 55113 <br />(6S1) 792-7036 <br />1Vlassage Therapisi I�icense <br />New License Renewal !V <br />For License year ending June 3fl �v�� <br />1. I.egal Name �c-LCI�e L�7�2 f�/ ri.�• ��-��'�� <br />n <br />2. Home Address - �- �«e�y /�V ,�,5 [} ( y <br />3. Home Teiephone � <br />4. Date of Bir[h � <br />5. Drivers Lrcense Number_ { l�J __ <br />6. �mail Address <br />7. �lave you ev�r used ar been Ecnown by any name other than the legal name given in number 1 above? <br />Yes No _� If yes; list each name a�ong with dates and places where used. <br />8. Name and address af the li�nsed Massage Therapy Establishment that you expecT to be empl <br />0 <br />a�v11��; ��2- <br />9. Attac� a certified copy of a diploma or certificate of graduation from a school of massag� therapy <br />including a minimum of G00 hauts in successfWly completed course wark as describecf in Roseville <br />Ordinance I 16, massage Therapy EsiablishmenCs. <br />10. Have you had any previaus massage therapist license [haE was rev�ked; saspended, or not renewed? <br />Yes No �_ If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Rosevilfe <br />