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r� <br />��4. k <br />�•{' <br />r1 <br />��r ��- <br />�+�� � � <br />��r � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License Renewal � <br />For License year ending June 30 <br />F <br />i_ L2�y8: *I�'F]� �1� �Tti ��� '�--����� j'�� — — <br />_. ' ~ ' • - ' '' .'� . • a . '� <br />w. libr� J��a� , .. . . . v ;�x - ; � r � <br />3. Home Tel�phon�, _ � -, _ , _ . , . .. � . .. ._. . _ . <br />4. Date of Birth <br />5. Drivers License Number <br />� ir,+e� <br />6. �zxiai� Address � <br />7. Have you ever used or been known by any name other tha�l the legal name given in number 1 above? <br />Yes No � If yes, list each name along with dates and places where used. <br />$, Name and � ess of the licensed Massage Therapy Establishmentthat you expect to he employed by. <br />�� b- 4� �� <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of inassage therapy <br />including a minimum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous sage therapist license that was revoked, suspended, or not renewed? <br />Yes No � If yes eaplain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />