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��j`� -�' <br />� � �� � <br />.,,�.,► � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55�I3 <br />(651} 792-7036 <br />Massage Therapist License <br />New L.icense F�ene�ual <br />For License year eitdi�lg J��ie 3U � Q�� � <br />1. Legal Name 2-( G G � ,N (� � �� � � � � <br />2. Hotne <br />3. Homc Tcleplioi � '� <br />/ <br />4. Date of Birt�� <br />5. Drivers License Ntmiber _ _ . _ <br />6. Email Address <br />• , � , <br />v <br />� <br />7. Have yau ever uscd or bee» knaw�i by ai�y nanre ather t17an t,l�e legai ��ame given in ciumbcr } abave? <br />Yes � No If yes, lisC each na�ne along with dates and places where used. <br />8. I�ame and address of the liceused Massage TheraE�y Estab]islvnet�C that you expect to be empJoyed by. ' <br />S E �N £- �3 8 r7 �� 2►4- b Z. 2d �,. _�as e u+ l/e. <br />9. Attach a certified copy of a diploma or c�rtificate of graduatio�� frort� a scl7oo] of massage therapy <br />including a miniti3um af 600 hours in successfu]]y compieted course �vork as described in Roseville <br />Ordulance ] ]b, n�assabe Therapy �stablisli��iei�is. <br />10. Have yau had ai}y prevrous mas age tl}erapist license that ���as reva�Ced, suspended, or no[ re�lewed? <br />Yes No � lf ycs cx�lain in detail. <br />License fee is 75.00 <br />Make checks payaUle ta Cit�� of Rosevi]]e <br />