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�� �4��� � <br />,���v � � � � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />�- <br />New License Renewal 1/ <br />For License year ending June 30 ���� <br />, ti . , ���. �._ � _ <br />L. Legal Name - <br />� <br />�. Home Address �`��-.-� .� - ��;�,,��,`�� ���� � ��, �� ��_ ' -,�� `���.�� <br />� i T� ... l <br />� _.._ , , •�_•.' a � � _ • ' - <br />3, Home Telephone " — --�. - �- . . _ -,°_ - � - - .— .-- - - ��, , 41 � . — <br />� rr i � r. , ti— — <br />�1. Date of Birth _ •. � � � <br />. .__ � - � , _�,� r:; . , : � <br />I •. <br />�. Drivers License Number � ���� <br />�, T'��f�id ri.�lc:��ss <br />� -- <br />,. Have you ever used or beeii kna 7fby any name other than the legal name given in number 1 above? <br />Yes No � Tf yes, list each name along with dates and places w�re used. <br />�. � zm � a_�:] adtres� c�= i'_:�. I i�� isLtid ��{i,saet� Tl ic�-���}� �14�1 �sh�enJ� �li�[�y+o�i u� t��l t�� bu ti�5 _�[t};�u�T �}�. _� � <br />� -�� i � € � '� � <br />--����� C 1.x� C��� ����� �� _ � � � �� �� . ��-� . �. � �.�.� <br />� �� � � �� � ���� � � �� � � � <br />.�� -_�� � � <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a miuimucn of 600 hours in successfully �{ �3�'-4t�f ��uas� ���rk a� d�s�rE�{v3 a� 1��•:al� � <br />Ordinance 116, massage Therapy Establishments. � � ��� ���,,_� � ��,��.} ��� � � � �� ��_� 1 � <br />1 <br />10. Have you had any previous r��� e therapist license that was revoked, suspended, or not enewed? <br />Yes No� If yes e�plain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />