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��'�'� . <br />��., � � � 1 <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, M� 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License <br />Renewal <br />For License year ending June 30 �, C��] <br />� <br />1. L�gal Natne r� i�F� {�'�t�{c� � <br />� <br />2. T-�o�ne Addres� — -- --.. _ . _� <br />—�--- <br />3. Home Telephone ° � ' "� `'` ' ' X <br />4. Date of Birth <br />5. Drivers License Number , , _ <br />6. <br />7 <br />���r aaa�ess <br />� � tJ <br />..., ��r <br />Have you ever used or been known by any name other than the legal name given in number 1 above? <br />�� No Ifyes, list each name along with dates and places where used. <br />8. Name and addra�. +�f E�r.xxw.� <br />�� � � <br />�dr�y+ F�l�l��l�,a�t that you expect to be employed by. <br />9. Attach a certi�ed copy of a diploma or certi�cate of graduation frttiin a school of massage therapy <br />including a minimum of 600 hours in success�ully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous nraassage therapist license that was revoked, suspended, or not renewed? <br />� �.__ �` � — Ifyes explain in detail. <br />License fee is 75.00 <br />Make checks payable to Ciry of Roseville <br />