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2007_0507_packet
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1/10/2012 12:38:43 PM
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Roseville City Council
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Council Agenda/Packets
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���� '� <br />��K <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />� <br />New License � Renewal <br />For License year ending June 30 _�' ��f <br />1. Legal Name ���I ) �� , � � `���: � _ _ <br />• �� � _ <br />2. Home Address _ <br />3. Home Telephone <br />4. Date of Birth � �_ <br />5. Drivers License Number– <br />�--i <br />6. Email Address — � <br />� <br />f <br />f1 <br />1 <br />7. Have you ever used or been known by a��y name other tl�an the legal name given in number 1 above? <br />Yes - _ No If yes, iist each name along with dates and places wiare used. <br />8. Name and address of the lice�,sed ssage Therapy F,,stahlishment that you expect to be employed by <br />i�-� � nI ��.� ��i.� 1�` ���� t t I <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a mii7i�n�en of 6001�ours in successfully completed course worlc as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any ���'j{}i�� ��;�" �erapist license that was revolted, suspended, or not renewed? <br />Yes . No If yes explain in detail. <br />License fee is 75.00 <br />Malce checl�.s payable to City of Roseville <br />. , -� <br />
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