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��-� i.�i _ �LLY T� <br />� <br />Finance �ep��°�����, �..,���ns� Division <br />2660 Civic Center Drive, Roseville, N�l�i 55113 <br />�6���792-7034 <br />�;�5��� �� ��'� �l i �� I� I��T15� <br />_New License � _ . Renewal . . .. _ <br />For License year ending June 30 __��� <br />��. Legal Name ��i���E�J� �� 3 <br />� <br />2. Home Address. � - x�i��F. �-,F=_�- _ <br />3. Home Telephone <br />4. Date of Bir��. <br />5. Drivers License Nutnbe.r <br />6. Ezraail Address <br />7. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes _ _ No _ � _ If yes, list each name along with dates and places where used <br />R. �arne ��id � i�� r Ti�er�xed �i�s�5s� Ti3ir.raar� F:s��ki]i��i7ser�[ thst +�o� c�c t 1� ��� ����yloyed by. <br />_ L� ��� �Y'�r� '�i � �s.�.��1. �� � � <br />� - l�� . �� <br />9, Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have �r� t���i a�u �r�vaous �a�a�e therapist license that was revoked, suspended, or not renewed? <br />Yes ���_ If yes e�plain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />