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�`� � <br />��►� ! � . �.�..�.. � t�� <br />� <br />Finance Depar�ment, �icense I��vision <br />26Gp C�vic Cente� Drive, Rosevii�e, IV�N 5�1I3 <br />(6Sl) 792-'103� <br />Massage Therapist �icense <br />New License Renewal <br />For License year ending June 30 (1� <br />��, <br />i. Legal Na�ne �-�ir11 ��� 4:.�� 4Q � �J �.. <br />� ,. . • _ <br />2. Hame Addressµ w ._ , � r ��u�_. ,,. „ -- � `' - y �. <br />3. Home Telephone_ ',(.�. �,_�_� ._� ,� <br />4. Daxe of Birtl� <br />� <br />5. Drivers i,icense Nurr�ber � - �,•e = <br />6. Email Addres <br />u � "a <br />� <br />7. Have you �v •� us�d or b�en �own. by any nanne other than the legal na�ne given 'rn neunber 1 abov�? <br />Yes _____ • No _ _ Tf yes, list each name along Wiih dates and places where used. <br />• � , ,. s ' <br />—�. � <br />8. ame and address oithe Iicensed Massage Tlierapy �stablzsl�zz�ent t.�at you expect ta �e e�ployed by. <br />�.L �1il�S - � C�. � _ � �� �LM,u� . �' # .�. <br />9. Attach a certi%ed copy o£ a diploma or certificate of graduation from a sehool of massage therapy <br />including a aninirr�um nf b00 �aurs in success�ully caznpl�ted cauz-se wor� as described zn Roseville <br />Ordinance 116, massage Therapy �stablistunents. <br />10. Have you lzad any previou age therapist license that rx+as revoked, suspended, or not renewed? <br />Yes No _�� If yes explain in detail. <br />License fee is 75,00 <br />Make checks payable ta City of Roseeille <br />