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� ���� � „ ��� <br />� <br />Finaz�ce De�aaxt�ea�i, Lice�se Divisian <br />2660 Civic Center Drive, Rose�ille, 1VIN 55113 <br />(G51) 792�7034 <br />l��s�age Therap�s� L�cen�e <br />New License � Renewal <br />� <br />For License year ending June 34 <br />1. Legal Name % � .' �r-t� ;�i'� <br />2. Hoine Address ,_ „ <br />_ � _ _ � � ����r <br />3. Ha�ne'I'elep�ane_ <br />4. Date aiBirth <br />5. Drivers i.icense Nuir�ber <br />6. Emaii Address <br />7. Have you ever used or been known by any name othea� thazz the legat na�ne given in number I above? <br />Xes No _� If yes, list each naine along with dates and places where used. <br />8. Name and address of il�e licenscd Massage '�13era�y �stablisi�ment tl�at you expect to be emp[oyed by. <br />'��(�x-�__.._._..._.�. � � u l <br />9. Attach a carti�ied capy of a diptoma ar certi�cate o�graduation from a schooI o�massage therapy <br />irxcluding a mizai�nurn af 6QQ laaurs in success�'�Ily co�npleted course wo�•k as described in Rosevilte <br />Qrdina�ce 11G, massage Tl�erapy Esta6lishmex�ts. <br />14. Have you had any previous massage therapist license ihat was revoked, suspended, or not rene�ved? <br />Yes No �_ If yes explai�� i�� detail. <br />�icei�se fee is �-5:�3fl�' .� � 5'�c� f! � f.�. ;, .— <br />Make checks payab�e to City ofi Roseville <br />