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��� � <br />� <br />�`an�n�e Depariment, �,�eense l�ivas��� <br />2660 C���c C�r�t��° D�iv�, Ros�v�il�, MN SSl l3 <br />�6�1} 792-7034 <br />Ma��a�� 'I'herapf�f Lrcen�e <br />New Lacense i�enewaI "> <br />For i.icer�se year ending June 3� ��'� � <br />1. Legal Name �..�o ! 5 �.r r-s �7 �' �r'f�ti � �a r �,�1 �.�- <br />2. Hnme Address . , - <br />l � <br />3. Home Te3ephone� <br />4. Dat� of Birth <br />�~~~..y--- <br />5. Drir�ers Lice�se Numbe <br />6. Email Address <br />-- .r .. ..r- ,_. �1 _� ., r� : 7 , �- . <br />7. Ha�e you ever used or heen lcnown by any name other tl�an the legal name given in number ] abave? <br />Yes � � No _ _ If yes, list eaclz name alon�; with dates ar�d piaces where used. <br />8. Narr�e and address of the licensed Massag� Therapy Establishzne�at that you expect fo be employed by. <br />�`F�r_tDr-F��-1'S i (�-�' �� �`o �� �.a ����Q �Ct�c.�� <br />9. Attach a certified copy a�a diploma or ce��tificate of graduation from a school of massage fherapy <br />incivding a minirnum of 6�Q hours in successiully completed course wnric as d�scribed in Rosevil�e <br />Ordinance I I6, massage Therapy Establishmenis. -- <br />1�. Have you had any previous r��assage it€ecapist license that was revofced, suspended, or not renewed? <br />Yes_ Na _ _ if yes explaan in detai[. <br />License fee is 75.00 <br />Make checks payat�le to City of Rasevil[e <br />