Laserfiche WebLink
''���,,,`� � <br />j ...� �� <br />� <br />Finanee l��p���ment, L�cense TDivision <br />26G0 Civ�c Center Drive, Rosevil�e,10�N 55� l3 <br />�dsi� �sz-�o�a� <br />11'�assage 'Y`�erapis� Licer�se <br />New i,icense Renewal �� <br />k'nz License yeax e�d'zng �une 3Q <br />1. Lega1 Na�ne � " �h� �l�i��v-� � �. _ �(�) ,, 1�- _ _ _.. �. _ . <br />2. Home A� .. �� _ _ . _,_ . _. � , . . _� _ .. " ' -- ' . <br />_ „ <br />3. Hame �'elepk�o�ae_ , <br />4. Date of Birth ' ` <br />_. . �.. _' � _ ..� <br />5. Driv�rs License N�umber ,+ ..� _, , �, ,,_�_ _-, � .� <br />• 4 ; r_. • , <br />6. Emazl.Addze�s �, <br />V � � <br />7. Hav� you ever used or been ��nwn by az�y zzam� other than the legal ztam� givei� in n�uznber 1 above? <br />Yes _ � No , If yes, list eaeh naane along with dates and places where used. <br />8. Name and address of the licensed VTassage TheraP�y�stablishrnent that ypu expect to be employed by. <br />�. ; �''�-,� = � �c (t .' O � l � <br />9. Attac�7 a eertified cnpy of a dipinrr�a or certi�cate of grad�atioa� from a school of massage tl�era�y <br />�acluc�iz�g a z�izzixz�uzn of GOO l�aurs in successfuily completed caurse wax� as described in Roseville <br />Orda�ance 116, anassage Therapy �stabiis�ents. <br />1(1. Ha've you had ar�y previous ma age therapist license ihat was revoked, suspend�d, or i1ot renewed? <br />Yes No � F� yes ea�plain in detail. <br />3.,icez�se %e is 75.�?0 <br />Make c�ecks payable to City of Roseville <br />