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%% �� � <br />� . . <br />�in�a�e� Dep��memt, Lice�as� l�iwisi�� <br />2660 C`��e Ce�te� I3��ve, Rcas�v�lle, �I�I 55�13 <br />(651) 792-7434 <br />l��s�a�� '�"he�°api�t �.�c�n�e <br />New T,icense � Renewai <br />�or License year ending June 30 `i,GC'�� '� <br />1. Legal Name�J �.C= �1`1 +� � � �� � ' 1nG�` <br />�m <br />2. Home Address � <br />3. Home Telephc � <br />4. Date a� Bir�h : <br />5. Drivers �,icense NumbF <br />6. Email Add <br />ca <br />7. Have you ever used or been #rnown b� any name oiher than the legal name given in numbez 1 ahove? <br />'Yes � No � ._ T�yes, list each �ame along with dates and places where used. <br />8. Name and address a�th� licensed Massage Therapy �stab�is�ment that you expect to be enr�pinyed by. <br />� l'r,. -� J� �c; ',...�! ,�`a ��� ` .�. j �,� �, -C:�2.�5���'7 ��c� 5 v�n�.1�, 1 �, �� �'. � <br />2�>Se,,.��� 11-� , lv��tJ Ss ��� ' <br />9. A�ch a neriifed capy of a diplama or eerti�icate of graduation fi-om a schnol of ttaassage therapy <br />i�cluding a minimum of b00 hours in success�ully cocz�pleted course work as described in Rosevi�la <br />Ordinance 115, massage Therapy �siablishments. <br />10. Have y��r had any previous maGGa�e tiherapist �icense that was revoked, suspended, or not renewed? <br />Yes � No � If yes expla� in detaii. <br />�icense fee is 75.QQ <br />Mak� checics payable to City of RoseviTle <br />��-, <br />r,- <br />