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�� I� � � Y ; <br />� <br />Fina�ce Deparfinent, License Divisio� <br />2660 Civic Cenier Drive, Roseville, MN 55113 <br />(G51) 792-7034 <br />Massage Therap�st License <br />Ne�rr License Rez��wal `' <br />Far License year ending June 34 �� _ <br />l . Legal Narz�e �G�,��� �6�'tV�P _.� `v'� <br />���i � . . ...... .. .... .....__ _ <br />, f <br />2. Horne Addtess ::. .,. . <br />,w .. . . : ..,. <br />_.. _ ....:., _....:...� .- _ _ �4 f. <br />�. �O�SA� TE�C��10I1� ti .� r ""' . .., _ <br />ti <br />4, Date of Birt% ' <br />S. Drivers License Number <br />6. �znail Address ` � <br />7. Ha�e you F �aed or been kr .,y any name other �an the legal ��an:�e given zn n�u�ber 1 above? <br />Yes � No __ Tf y�s, �ist each natne along wiC�. dates ar�d places �where used. <br />8. ame and address of the licensed Massage Therapy Establish�nent t�at you expect to �� e�zp�oyed by. <br />� `" .��,�� ��� � �a,rn� �.�,,.� -.� ,C� �7I <br />9. ATtach a cerfi�ed eopy of a dipioma or eertificate af graduation froz� a school of massage tt�erapy <br />including a minirr�um of G4Q houz�s in successfuily completed co�rse �rrork as deseri�ed izi Roseviile <br />Ordinance 11b, znassage `i'herapy Establishrnents. <br />1(3. Have yau had any previous znas e therapist Iicense that was revoked, suspended, nr not renewed? <br />Yes No Tf yes e�Iain u� detail. <br />License fee is 75.0� <br />Make ck�ecks payable to Gity af Roseviile <br />