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Attachment A <br />�3 i�;� -� <br />���m im n <br />� �`— � � <br />Finance Department, License llivision <br />26G0 C�ivic Ce�ifer Drive, 17oseville, 1V1N 55113 <br />(651 } 792-7036 <br />Massage Therapist License <br />New License �/ Renewal <br />For License year ending Jwie 30 � 1� <br />t . Legal Name ��2 <br />� ��..---�� �ti'1 ' �1( �c ;�� F � z... — <br />2. 1-Iorne Address <br />3. Hon�e Telephone <br />4. Date of Birtl� <br />5. Drivets Liceuse Number <br />6. Email Address _ �,�,,,.�, t , �. � _ _ L�` <br />7. Have you evcr used. or been known by ai3y name other tha�� tf�e iegal nan�e givec� i�� numl�er 1 above? <br />Ycs ��' No ]f yes, �ist each �iame aloi�g witll dates and places �vhere used. <br />r�� <br />S. Name and address of thc fice��sed Massagc Therapy Establrsl�ment diat you expect ta be employed by. <br />�-�'�1� \h� �_ �� �`��� . <br />9. Attach a certified copy of a diploma ar certificate of gi•aduation from a school oF inassage therapy <br />including a minimuu� of 600 hours in s�iccessfully campieted course work as described En Roseville <br />Ordi��aiice ] ]b, massage Therapy Gsta6lislmle�its. <br />10. Have you had a��y previous massage tl�era�ist ]icense tl�at �a�as revoked, suspende�, or noi rcncwed'? <br />Yes :X No lf ycs explain in detail. <br />License fee is 75.00 <br />Make chec�CS payable to City of Rosevillc <br />