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�� ��'I-� <br />Finance Departmeut, License Division <br />2G6� Civic Center Drive, Roseville, MN 55��3 <br />(551) '792-7036 <br />1Viassage 'Therapist I.i�ense <br />Ne�v License iL Rene�val <br />�'or License year ending June 30 <br />1. Lega1 Name ��i iC"�{ �'L �-�-� � <br />2. Hotne Address 3� a z- �.�� � cs�, �-� ` �j'� , 2� l� ��i.10 c�. !y)l�/ S.�!!� <br />3. Home Telephone <br />4. Date af E3irth <br />5. Drivers License Number <br />6. Email Adciress <br />7. Have you ever used or been ]cnocvn by any narne other than the le�at name giuen in number 1 above? <br />Yes No �.__ If ves, list each name along with dates and placcs where used. <br />8. I�Tame and address of the licensecE Massage Thera�y Establisiunent �th4a_t you expect to be employed bv. <br />(� 3v��.S �, `�u.��—_itil�!x.,�.�_e_ � tr C,�-. • .�. ��-� <br />L� —�� r f�. �_ �. <br />9. Attach a certified cnpy of a diploma or certificate of graduation from a school of massage therapy <br />including a minunum of 600 hours ir� successfully cnmpEetec� course work as described in Roseville <br />Qrdinance � fb, rriassage Therapy Estahlishments. <br />[ 0. Ha��e.you had any previous massage therapist lieense that was revoked, suspended, or not rene�vec�? <br />Yes No �.— jf yes explain in detail. <br />License fee is 75.Q0 <br />Malce checks payable to City of Roseville <br />