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— � <br />�. <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, � 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License �� Renewal <br />For License year end'mg June 30 <br />� • L�E N� _��„�1�, �,�, ���,AV1 �n—��. ��� <br />�- Home Addres: ' �� � r ` ' ` <br />FP� <br />Y <br />3. Home Tel�phane_ _ _. <br />� <br />�- Date of Birth <br />�_ Driven License Number � � <br />�, �ma�X Address f - � �. ..._. — <br />� <br />7. Have you ever used or been knowrf iry �n name other than the lega� name given in number 1 above? <br />'�� _ _ �+i� _ �yes, list each name dong v�h dates and places wh�z�e used. <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />�riL��—�.� rii�L 4� U k��*r.�-4�-�i' r � r� t�.� <br />9. Attach a certified copy of a diploma or certificate of graduation fi�nr a school of massage fih�ra�ry <br />IiiC��I(�ill� a mi nimm �rtn of 600 }}our� in successfully completed course work as described in Rvsevi�le <br />Ord'mance 116, massage Therapy Establishments. <br />. � <br />10. Have you had any previous massa pist license that was revoked, suspended, or not re� <br />Yes �� _ — Lf yes explain in det�L � <br />License fee is 75_O(3 <br />Mal�e checks payable to City of F�aseville <br />