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��`�� . ""`�.. � . . <br />.,,�r' . ....�al� �� :,�` <br />Finance Departmeni, Liee�se Divisioz� <br />2660 Civze Center Drive, Rc�seviile, MN 55113 <br />(65�} 792-'7034 <br />N.�assage Tl�erapi�� Licen�e <br />New �.icense X �enewal <br />�'or License year ending June 30 '�-� 6 <br />I. Legal Name� i�G4..3 �.1:�-q l� L�-1�i <br />2, Ho�ne Address �_. F � � . � . <br />3. Hame Teiephone� . <br />4. Date of Birth <br />5. Drivers License Nurnber <br />6. �maif Address <br />7. Ha�ve you ever used or beer� [cnown by aray name nther than the legal name given in nurxaber i above? <br />Yes No �_ �f yes, list aach name along with dates arad places where us�d. <br />8. Narne and address of the 13censed Massage "I'herapy Establishm�nt ihat you expect tn be employed by. <br />���� " � "�e�� 2�C,�._ f n�.r <br />. � , . <br />9. Attach a cert'rfied copy of a digloma ox certi�cate of graduation from a schnaI of massage therapy <br />inciudin� a tninirrtuin oiG470 hours in success�ully comp�eted coursc work as described in Rosevi9fe <br />��•dinance I 16, massage Thera�y �sta�tishrnents. <br />10. Have you had any previous massage therapist Iicense that was revaked, sus�ended, or nat renewed? <br />Yes No �,,_, if yes explain in detail. <br />�,icense %e is '15.00 <br />Ma[ce cheaks payable to City of Rosevai[e <br />