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�� � <br />,�.���v 1 , .� � � <br />Finance Department, License Division <br />2660 Civic Center Drive, �.2c���vi��e, MN 55113 <br />(651) "7�2-'7Q�� <br />I�a� � a�� 'T� �x����t ����� �� <br />New License Renewal �� <br />For License year ending June 30 W C] <br />1. Lega1 Name �'-�t�� i ��� E,� �' <br />2. Home Address � � � �� ' � � � - � �:�-.,� �� f ' ' �? <br />• . ;, -a, �.r�'- <br />3. Home Telephone ; _�„ ,_ ,,,. <br />4. Date of Birth—,...,A; , , - . _ _ _ <br />. , t .� • , <br />5. Drivers License Nu�nber � � � � <br />-.l,- .. ._- . . •"r • . , ' .sr- <br />6. ��ai� Address - ; � , - ° ' n_ , <br />7. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes ___� No � If yes, list each name along with dates and places w�r� used. <br />8. Name and address of the licensed Massage Therapy Es�ablishni t t��at �» expect to b�: employed by. <br />r��� lw�� w ��-1`�'��f ���rl �-'� ���f�::�.�.�.ti�' ��� � <br />�� � , ��5"�� <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a�x� ��ni�n�n of 600 hours ir, successfully completed course work as described in Roseville <br />Ordinance ll6, massage Therapy Establishments. <br />10. Have you had any pr�����s ri� sa�� therapist license that was reyoked, suspended, or not renewed? <br />Yes N�a � If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />