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�� �� <br />� r �� � <br />Finance Department, License Division <br />2660 Civic Center Drive, Rr�seviiie,lW11V 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License �� Renewal <br />For License year ending :�utae 30 <br />c "F � - .• <br />1. Legal Nam� ���4�, ;�� i f� -� <br />2. Home Address <br />3. Home Teiephpi _ _ _ <br />4. Date of Birth <br />5. Drivers License Number� <br />� <br />6. Err�ail Address _ _„�--� — � _ _�. <br />� `_` <br />7. Have you ever used or been known b�+���natxae other that� the legal name given in number l above? <br />Yes. —�¢ — _ If yes, list each name along with dates and places where used <br />8. Name and address of the licensed Massage Therapy Establishment�f��� �7u eXpec� 14 �knpa� ��. ���� �� �� <br />� � ��� <br />�1j 1 Y�P � d-��fk��,l� I �_ �• � �� � 71 -�'. ' r�.� StiI ��-�' j <br />- , �:��+,x <br />9. Attack� a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 64(� hours in successfully completed course wark as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous rr�assag�E�rapist license that was revoked, suspended, or not renewed? <br />Yes _ No _ If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />