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��'� <br />� <br />Finance Dep�rtment, License Division <br />2660 Civic Center Drive; Roseville, MN 55�13 <br />(b51) 792-7036 <br />IV�assage rTherapist Li�ense <br />New License Renewa] ,/\ <br />For License year endin� June 30 <br />l. Lega] Name� _. ���1 �'�!'�n i� �,��t/1'Z...�� <br />1��- - - _._ .._ <br />2. Home Address <br />3. Home `F'elephone _ . _ _ _ <br />4. Date of Birth <br />5. Drivers License Number _ , , � _ _ , . <br />6. Email Address � k - - <br />� <br />7. Have you ever used or been known by any name other than the legal name given in number I above? <br />Yes No ___ � _!.f yes, ]ist each name a�ong with dates and. places where used. <br />S. Name and address oithe licensed fvlassa�e T'herapy �stablish.ment that you expect to be empfoyed by. <br />�.���v1 �e. �3o d -m - <br />1 � 2 °� w • C� f . i�- �t . G __ . . <br />lzc�� �� � 1 N1 ��� � 13 <br />9. Attach a certified capy of a diploma or certificate af graduation fram a schoal or massage therapy <br />including a minimum of 6Q0 hot�t-s in successfully completed course work as described in RoseviJle <br />Ordinance ]] b, massage Therapy Establishments. <br />]0. Have you had any previous massage therapist license t.hat was revoked, suspe�tded, or not ren�wed? <br />Yes No -,� {f yes explain in cietail. <br />Lrcense fee is 75.04 <br />Make checks payable to Gity of E2oseville <br />