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�� <br />�4�� <br />����. <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License <br />Renewal ��ti <br />For License year ending June 30 f� <br />� _.. a � <br />1. Legal Name � � � <br />2. �pfne A ddres� _ <br />3. �om� Telephone- <br />4. Date of Birth <br />5. Drivers License Number- <br />5. E�ai� Address- <br />_ :.�...,. .� <br />1 <br />�, Hu,r� ��r�b ������� used or �ee��. known by any name other than the legal name given in number 1 above? <br />- 'l es _ �_ __. No � If yes, list each name along with dates and places w��'e used. <br />8,. ��ai� and addre.�s uf lLi� 1 iCe i7�ti� MAS5r�G �th�rup}� Lkl,i a l i sll>>�c'I�t 1 �7�3i,� nti: txq��.[ �o btikcr�p2u ��d b}�, <br />f ��ri�]��� __ ���_ Y��--�! �� �!��i�i±�����; �5 �x�";t��14 ����.��� <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a rnzn�mta� of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any preyious assa�e therapist license that was revoked, suspended, or not renewed? <br />Yes �' `� �-: If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />