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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 />�� :k; u � j•:t itit �� Renewal <br />For License year ending June 30 <br />:�:•.�! �.��,��. ����� ����.rfJL _� r��'��-Y��v']�E'y? <br />2. Home Address, <br />y� -`- • i- � <br />3. Home 1 L IL}�I �;: �:•: ,� <br />4. Date of Birth, <br />5. Drivers License Nuinber <br />r <br />6. Email Address <br />7. Have ����� �'��r� used or been lcnown by any name other than the legal name given in number 1 above? <br />Yes ��' — If yes, i_isr e�c1_� name alc�ng wi.th dates and places where used <br />i. <br />8. Name and address of the licensed Massage Tht'r�-�� r'�:i,i�'i �'�-rr•.•�t th-at yoJu eX¢"r'f '+� 1+" i'��i'>yed bv. , <br />�ona�� r; � ���� � �,S ��#� ���_�����? � ��f�� <br />� � � r-�rti � <br />9. Attach a certiiied copy of a diploma or certiiicate of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course worlc as described in Roseville <br />Ordinance 1 16, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revolced, suspended, or not renewed? <br />� <br />Yes No �"� If yes explain in detail. <br />License fee is 75.00 <br />Malce checics payable to City of Roseville <br />