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���,.,,.� J . ,__ � 1 J <br />Finance Department, License Division <br />2664 Civic Center Drive, Roseville; MN 55113 <br />(651}792-7U3G <br />Massage Therapis� License <br />wio mmmmmommo — on— <br />New License Renewal V <br />For License year ending June 30 �010 ^_,___ <br />1. Legaf Name 11 <br />__ . � <br />2. Home Ad�lr�es <br />3. Home l e�ephone -- - - - - <br />4. I�ate of Birth <br />5. Drivers License Number <br />6. Email Address <br />7. I-Iave you ever used or been known by any na��e oiher than the lega] name given in number 1 above? <br />Yes �� No If yes, list each naane along wi�th dates and places where usad. <br />-.� _ . ' - — � � <br />8. Name and. addr�ss of 3he ]icensed Massage Therapy Establishment thai yo�i expect to be employed by, <br />�Y,c��� .�¢$D ir " iL/� , �d�5.�/l3 <br />9. �lttacl� a certif�ed copy of a diploma ar certificate of �raduation from a school of �n�ssage therapy <br />incltiding a minimum of 60� hours in successf��lly completed. caurse work as described in Roset�ille <br />Ordinance 1] 6, massage Therapy Establish�nents. Cp/7 ���j) <br />10. Have yau had a��y previous massage therapi.st ]icer�se Chai �vas revoked, suspenc�ed, or nat renewed? <br />Yes� I�?o j� If yes explain in detarE. <br />License fee is 75.00 <br />Make checks payable to City of Rosevr]]e <br />