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�� �� <br />� <br />Finance Deparirnent, License Division <br />2G60 Civie Cente�- Drive, Roseville, MN 55113 <br />{651) 792-7036 <br />Nlassage T'herapis� I�icemse <br />0 101A . plPr� �� _ ___ - <br />New Ltcense Renewal � <br />For License year ending June 30 ���� <br />1. Legal Name <br />2. Hatr�e Address <br />3. Ho�ne Telephone� <br />4. Date of Biz�th <br />1 �, <br />S. Drivers i,icense Number <br />6. Email Address .�, , , <br />�� <br />� <br />���5:. , <br />s,.��!ss� <br />7. Have you ever used or been icnown by any name ott�er than the iegal name given in number � above? <br />Yas Na � If yes, list each name along with dates and places where used. <br />8. Na�ne ar�d address of <br />�� i� ��A t� <br />Therapy Esta.blishmerrt that yau expect to be employed by. <br />9. Attach a cartifed copy of a diploma or certif�cace of graduation from a sehool of massage therapy <br />including a minimu�n of 600 hours i.n successfully campleted course work as described in Raseville <br />Ordinance t 16, massage 'i'�erapy �stabiist�ments. <br />l�. Have you had any previous mas� therapist licer�se khat was revoiced, susper�ded, or not renewed? <br />Yes No �� If yes explairi in detail. <br />License fee is 75.00 <br />Make checks payabie to City oF Roseville <br />