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, �� r <br />.,�� �4"������"�'i�'� <br />�; <br />�'inance De��rtaaent, L�c�nse Division <br />2660 Civic Ce��er Drive, Rasevi��e, MN SS�l3 <br />(651) 792�7034 <br />11�a�sage Th�rapis� L�cense <br />ew ' s� <br />Renewal <br />�'or �.ice€�se year ending June 30 <br />1. Legat Narne � , . �.-i' <br />2, Ho�ne Ac�dress_ _ __ — <br />3. Haine Teleplio��e „r _ <br />4. Date af Birth w -. , <br />5. Drivers License Numher <br />� <br />b. Email Address <br />� <br />7. Have you ever used or been k��aw�n by any name othex tl�an tkze legal i�ame gi�e�: in nunnber I above? <br />Yes _ No _� r . If yes, �ist each na�ne aiong witla dates and plaees whers used. <br />8. Nanie_and address of the licensec[ Massage Therapy Estat�lishanent.that you expect to be em�loyed by. <br />� <br />9. Attach a certi�ed co�y of a ciiploma or certificate of graduation froin a school of massage thera�y <br />izacluding a n�initnuin of 6QQ kzoui-s ia� successfully co�npleted course work as described in Roseville <br />qrdina3ice 116, n�assage Therapy �stabtishments. <br />l0. Have you had ai�y previous zna�age therapist lice��se ihat was revo�Ced, suspez�d�d, ar �nnt z•e�zewed? <br />Yes No �� _ If yes explain in detaii. <br />License fee is 7S.QQ <br />Make checks payavIe to City of Raseville <br />� 5 S"/ /3 <br />"�} 5����i <br />