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� �`. " , � t • � <br />Finance DL,�artme�t, License Division <br />2660 Civic Cent�r�Dri��e, Rosevitle, MN 55113 <br />(651}7�2-7036 <br />Mass�age The}�•apist License <br />T�e�i� License Rene�va] <br />For Licei7se year ending lune �0 ��Io <br />r � <br />I. �egall.�ame �a A�)N2 1`-�G �QJ -01��.7Z -_____— <br />'. Home <br />i F�ome Telephone <br />4. Date of Birth <br />-._,-„--�.—„_...----- <br />:;. Dt•ivers License 1�'timber �"' <br />G. Erriaii Address 3 <br />_ y._ v � <br />7. Have yois ever used or been kno�vn by any name oCher than tlie lega] nar�le given in number i abo�e? <br />Yes ��_ _____._ No If yes, list eac.h name aiong tivith dates and places ��here used. <br />T� <br />8. Nan�e and address of the licensed Massaga Therap;r Establishment that y�ou expeci Eo be empIoyed by: <br />����� ��� <br />---------� - <br />9. Attach a certified copy o# a diplo�t7a or certific.ate ��f uraduat'son from a sc�uol af massagc iherapy <br />inclt�dine a minimum of 600 hours in successfully cornpleted caurse work as described in Roseville <br />Ordinanc� 116, massaVe Tllerapy Establishments. <br />IU. 3-lave you had any previous massag� therapist ]ia�nse tliat was re�oked. suspended, or not rene�ued? <br />Yes� €�TO �� If yes explain in detail. <br />License fee is 75.00 <br />Make checks payab�e to City of Rasevilfe <br />