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Attachment A <br />�� � <br />.��' <br />Finan�e De�artment, License Division <br />2660 Civic Center Drive, Roseville, MN 551 � 3 <br />(65 ] ) 792-7036 <br />Massage Therapisi Licen,se <br />I�e��� License � Renewa! <br />For License year ending June 34 �� �� <br />]. I.,egal. l`'ame `} 2.1/1v� 4� �� t�� 1������� U�., <br />2, Hqme Address " "` � <br />- ._ _.._....� <br />, -- - . <br />3. Home Telephane� _ _ <br />- �..�rt <br />4. Date of Birth <br />� W - -- <br />5. Drivers License I�umber > � • - � • • ,- <br />b. �maif :'�d�ress <br />- J . - - -,. � u <br />7. Have you ver used or been known 6y any name other than fhe le�al name given in number 1 above? <br />Yes �� No If yes, list each name along wit� daCes and piaces where used. <br />S. hame and address af the licensed Massa�e Therapy �sta.blishment that you expect to be employed 6y. <br />�. � �.�-lVr'�.�- '�'�_$-c� �i�rl����� Drtl.�_ • �1��1 � f s.u.(i t �� �ri� �� � � <br />�F �1-� �S5 <br />9. Attach a certified copy of a diploma or certificate of graduation from a school o{ massage therapy <br />includin; a minimwti of 600 hours in successfully campleted caurse work as described in Roseville <br />4rdinance 1 l6, massage. Therapy Establishments. <br />]0, Have yau had any previou m ssage iherapist licei�se that was revoked, suspended, or not renewed? <br />Yes n'o � {f yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />