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����1 <br />� <br />Finance Departimenf, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(65�} 792�7034 <br />Nlassage 'I'hera�ist License <br />New License Renewal .``, <br />�'or License year ending June 30 � {}p t3� <br />1. Legal. Name � <br />2. Home Addres <br />_ , <br />3. Home Telephone .� <br />4. DateofBirth <br />�—. -. <br />5. Drivers I.,icense Number <br />n. Emai1 Address �^ f <br />7. Have you ever usec� or been known by any name otl�.er than the legal name given in. number l�bo�e? <br />Yes No .'� If yes, Iist each name along with dates and pfaces wlare used. <br />8. Name and address o th.e li ensed Massage Therapy Establishmen.t that you expect to be employed by.1 <br />. � � G� ��4 � ,� c:( � �'�i <br />lR o�S , � . C,Q f�Yi}� R. � �� � {�'D S�i/� � ! � . I`� 5 �� �� <br />9. Attacl� a certified capy of a diploma or certifcate o�graduation fror� a school of massage therapy <br />inciuding a minimtm of 600 3�ours in successful�y compfeted co�rse work as descri.bed in Roseville <br />Ordinance ] 16, rrtassage Therapy Establishments. <br />10. Have yoU had any previous massage therapist Iicense that was revaked, suspen.ded, or not renewed? <br />Yes No �� _ If yes expJain in detail. � <br />License fee is 75.Q0 <br />Make checks payable to City af Roseville <br />� <br />/ <br />