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� <br />�����'_�.�,__ �' <br />�� � � � � � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55ll3 <br />(651) 792-7034 <br />Massage Therapist License <br />New License � Renewal <br />For License year ending June 30 _�� �� r <br />�. ���� k ��IY!v �.��� I��.�'�� �lR'!"L4��.� I -��r.�t.-�l _ _ ,_ <br />� , � � � � . h <br />{ ti!.•�ll' S.��L11�'-. �� • —' . <br />3 Home Tclephone_ _ <br />r% _ � �.,� <br />4. Date of Birth � _ <br />5. Drivers License Nuinbe� <br />6_ Emai� Address <br />� Have you ever used or �ieen lcnown by any name other than the legal name given in number 1 above? <br />Yes � No � If yes, list each name along with dates and places where used <br />!L� ���iFiv �ixl �.�d� ��� :�2,�.1� IJu•a=sC.i ��,:4 L�,,;� � �:� I'�}�t• I�I •7 yl i�I iin �i�L 1I7�: ;:•�: k x r_�t'. I:y •:L' £'I :' I}I4ti,� t�i Iti} . <br />-#�l _ � �.�.� _�;, ��u�' �� ��. � t � ��.,����� �-`�-�: �� � � _ - - <br />��� �Yl���� �. <br />�`�.��t� �. t �� 55113 <br />g. Attach a certified copy of a diploma or cc�-tificate of graduation frorn a school of �nassage t��erapy <br />i»c3udi��g a t73inimu�n of 600 hours in successfully completed course worlc as described in Roseville <br />Ordinance 116, massage Tl�era}�y Establishments. <br />] 0. �Iave you had any previous massage therapist license that was revolced, suspended, or not renewed? <br />Yes __ �'' ,,,��„ I�' yes explain in detail. <br />License fee is 75.00 <br />Malce checics payable to City of Roseville <br />