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���� � ��'����� <br />� <br />Finance Depa�tment, L�ce�se Div�sion <br />2660 Civic Center Dr�ve, Rvsev�lle, MIiT SS113 <br />((51} 792-7034 <br />��.ssage Therap�st License . <br />New Lic�nse Renewal <br />�'nr �,icer�se year <br />1. Legal Natne <br />2. Home Address <br />3. �Fiame Tele}�i�one _ <br />4. Date of Birt�_ <br />5. Drivers T.,ic�nse Numbe�• a..,� •- ,_,�, , �� , , _ <br />� <br />6. ��nail Addreas <br />� �� � � , <br />i. Have you ever ��sed or been knn� by any nazne other than the legal nazne givezx iz� nrunber 1 abave? <br />Yes No � � ii yes, lzst each aiame along with dates and pIaces v�rhere used. <br />8. Name d address of �e licensed assa e�'herapy tab ' hment that ou ex ect to be e�nployed by. <br />.._ .................� ���1 �� �'�'� Vt � � � �i1,� � j(1� W , <br />9. Attach a certified capy of a diploma or certi�cate of gxaduation frozz� a se�ool of rnassage therapy <br />includizzg a minimum of 600 hours i�x succeasfu�ly corn�let�d cnuxse wark as described in RoseviIle <br />Ordinance 116, �nassage Therapy �s�ablishments. <br />10. Have you k�ad a�y pzevious �as age therapist licezzse t�afi was revoked, suspendect, ar nat renewed? <br />Yes�� No � If yes explain in detaii. <br />T,zcense fee is 75.44 <br />Make clzecks payable to City of Roseville <br />