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��� <br />� . .� <br />Fin��ce �3epart�ent, Licens� I�ivisian <br />26b0 Civic Center �}rave, Rosevi�le, MrT 55113 <br />(65i) i92-703� <br />M�s�a�e T'her�pis�i L�c�n�e <br />New License Renewal <br />For Licanse year ending June 30 <br />1. Lega[ Na,ne ` <br />2. Home Address_ � ' �' ' , [ <br />3. Home Telephone <br />4. Date of Birth � <br />" � . <br />5. Driv�rs License Number <br />6. Ernail Address <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 _�_ If yes, list each name along with dates and places where used. <br />S. Name and pad ress of the licensed Massage Therapy Establishment that you expect to be employed hy. <br />1 _r�l f _ .Ll�_i � � e�.,� r' L,'e��._....�....L � _ �-. f �•" . .t _ _.,_ .�, r . . <br />" ' � �2os� i i ie, �V �5 l t3 <br />9. Attach a certified copy of a diplama or certificate of graduation from a sehaol of massage therapy <br />including a rr►inimum of 600 hours in successfully completed course wark as described in Roseville <br />Ordinanee I 16, massage Therapy Establishmenis. <br />, <br />10. Have yau had any previous massage therapist Iicense that was revoked, suspended, or noi renewed? <br />Yes No �_._.___ If yes e�lain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseviile <br />