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���'�� � <br />�,�_s . : � ��� <br />Finance Departme�nt, Licen�e Divfsion <br />26b0 Civ�e Center Dri�e, Rnsevill�, MN 55113 <br />(�i51) 792-7Q34 <br />1'V�assage Therapist L�cense <br />New License � Renewal <br />,-� -- .�..,.�, <br />For License year ending June 30 ���0 <br />�. Legal Name _ ^ .� �S �" <br />� � .-� <br />Z. Hoz�-�e Address <br />� ..._ ...__ r <br />3. Hn�ne Telephane � . <br />A. Dai� nfBir�h <br />�. <br />5. Drivers �,icense Number <br />&. Ezzaail Address � <br />.. � ,.,,�„�„r„ �„ . ,� „ <br />.. � <br />7. Have you ever used or l�een known by any name atiier than the iegal naane given in numbex 1 abave? <br />Yes X No If yes, �ist eact� name atot�g with dates and plaees where used. <br />.� <br />, . � , <br />8. Name a��d a.ddress af the liceatsed <br />.n.. , .. 1 r'3 .. l _ 1 _ <br />Therapy Esta�lishYnent that you expect to be empiayed by. <br />� 1`1 �-1 r> C�; ��, a�rn--L . <br />9. Attach a ceirtified copy oi a dz�loma or ce�tzficate of graduatiot� from a school of rnassage ihe rapy <br />incl�diza� a mininium of 600 hours in successf�ally comp�eted course work as described in Roseville <br />Ordinanc� 116, massage Therapy �stablisY�ments. <br />10. T-iave you had atiy previous tnassage th�rapist license that was revaked, sttspendect, or not renewed? <br />Ycs No � If yes explain in detaii. <br />�.icense fee is 75.40 <br />Make c�iecks payabie to �zty of Rose�ilte <br />