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�'��►_� � <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 />For License year ending June 30 _ <br />i _ Legal Name _f ,�"i r � _ <br />2_ Home Address <br /><_ <br />3. I�ome Tele�ho��e <br />4. Date of Birth <br />5 brivers License Number <br />r, I-�ar .��7=�.�• <br />Renewal , x� <br />. . •,��:�. <br />, <br />. • . •� � �� , � ',. <br />r <br />�_ Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes _ _��� __ If yes, list each name along with dates and places where used. <br />! <br />�. �� end��dre� �� the i��er��exl �r.,�c��,'I htr�py ��taL�l i�h�r�nt It�at � �acpc�l ;[� l�e enipl�7yeci i�r, <br />�� �, - f �� , ' f� �} <br />� •, � � �.�� ���.. . _ �� ,i ��,��- - — <br />- • % � • �r •. 'lf� {l� � � <br />' +, . f � • r. ' � . l � f � �. <br />. r • ,.• . • • . '{• � � , 7'r . i . .•, .' <br />9_ ,�t�acl� a certi9 �ec� copy of a diploa�s� i�r certi�cate of graduation fi•o€�� a school of massage therapy <br />including a miEai�num of 600 hours in successfully completed course work as described in Roseville <br />Ordinance [ 16, �nassage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renew�d? <br />�'�� No _�r' If yes explain in detail. <br />� 5 <br />License fee is 75.f)4 <br />Make c�ecks payable to City of Roseville <br />i <br />. <br />