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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 />� <br />New License Renewal <br />, _ <br />,,_. <br />For License year ending June 30 •� <br />n „ <br />1. Legal Name ���� � '�ti' �,�1'�` �'� 'r � <br />. �� ` � _ ,.. —•�J� <br />�� � <br />2. T�ozne �1.ddres5 . -� _ � , , <br />3. ?uir� Telephone — <br />4. Date of Birth -- <br />5. Drivers License Number. <br />6. �.mail Address— „ � _ u <br />< <br />7. Have you ever used or been known by any name other than the legal nafne given in number � above? <br />Yes No � �f yes, list each name along with dates and places where used. <br />L• 4{ ;• ��2 <I}�1�:4�� t' i� � 1�4'r1S."{� L J�LiM1� ' C �_lt: }'}' ��i��_I�_'IIL1C k � �� �•?'= C'7L��r Gi CO � CIYI�}� ��� �]'• <br />— �� � 5 � � '-- €�'�� -�[� I�.1�� �' L+�� �� - � _. L�� �,�''. � � t t"� <br />9. Attach a certified copy of a diploma or cei�i�icat� of graduation from a school of massage therapy <br />including a nlini�un� of 600 hours in successfully completed course work as described. iir Roseville <br />Ordinance 116, n�assage Therapy Establishments. <br />10. Have you had any previous ri�ssa�e therapist license that was revoked, suspended, or not renewed? <br />Yes No _� If yes e�plain in detail. <br />License fee is 75.00 <br />Make checks payable to Ciry of Rosevi9l� <br />