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� <br />��� <br />��� <br />Finance �`lepaartmen�, License Division <br />2660 Civic Center Drive, Rnseville, MN 55113 <br />(651)792-7034 <br />Massage Therapist License <br />New License � Renewal <br />For License year ending June 30 r�-i���l <br />1 _ l.tti:�.l ��r��e �. �! �; � 'l ".. . 7 ��� �-.-- - � r �l�I ��� r���� �. .+ �� <br />2_ ��r�rr,� �ddtesa_ L . . . , -. f k,� <br />__ � <br />3 _ Home Telephone _ <br />i� �h � � <br />�] _ Date of Birth <br />5_ Drivers License Number L� � <br />�-+--- u �- — <br />� E�nail Address — <br />.. •� � � <br />-_ Have you ever used or been &n��x�y,L�� any name other than the legal name given in number 1 above? <br />Yes _ _ N� �._ If yes, list each name along with dates and places where used. <br />. . _' t . . . . ', ' .� �.' <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />, <br />Y-'f 1 � rti?.i; � r_.� � � •i � �{ ;� �_• l. <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of tr►assage therapy <br />inciuding a mini�num of 600 hours in successfully completed course wark as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previo»� m ��auP� therapist license that was revoked, suspended, or not renewed? <br />Yes 7`'� � If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />. i <br />,. � �� ... � .�� ., �. � . <br />