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��� <br />��" <br />Fenan�e Department, License Division <br />2b60 Civic Center Drive, Raseville, MN 55113 <br />(b5�) 792-7Q36 <br />Massage Therapist Ilicense <br />Ne�v License � Renewal <br />For License year ending June 30 <br />f, i,ega[ Name j s �� � <br />2. Home Address 2�5 33 �- �1�%� �, s. ���� � CJ M �c�i �iLS <br />3. Home TelephanE_ <br />� <br />4. Date of Birth <br />5. Drivers License Number <br />, � . , <br />6. Email Address <br />7. Have you ever used or been icnown by any name other Yhan the legal rtame given in number 1 above? <br />Yes No �__ __ If yes, list each name alon.g wit.h dates and places where used. <br />8. Name and ddress of h licensed Vlassa e Thera y Establishment that you expect to be emplo ed by. <br />1�s-� � P� 2u o�vartic-+�.� P�. .__. ��, �t� �t t� <br />9. Attach a cerE.ified copy of a diploma ot ceriiftcate of graduation from a schoo� of massage therapy <br />including a m.inimum of 600 houxs in successful[y completed caurse work as clescribed in Roseville <br />Ordinance � ]6, massage Therapy Establishments. <br />10. Have you�any pre�ious rrtassage therapist license that was revoked, suspended, not renew� e� <br />Yes No If yes ex�lain in detai[. <br />t �'' <br />License fee is 75.00 <br />IVlaice checks paya6le to City of Roseviile <br />