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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 ;� Renewal <br />For License year ending June 3��'��k��J � <br />1. Legal Name •..�� ��1� t� �- fi ,'uL• y�}_;� ��r~; <br />2 Home Address- • S r _ .� <br />3. Z�o�e Telephone <br />4. Date of Birtl <br />5. Drivers License Numb�t <br />6. �rt�ail Address-. <br />7. Have you ever used or been lcnown by any name other than the legal name given in number 1 above? <br />Yes �C No If ves. �ist r��h �enn alone with dates and places where used. <br />" L <br />8. Name and address a�ths lice�]nsed MasIsa�e Therapy Establishment that vou expect to be employed by. <br />,��-. �+'i�'•1't �i �L ✓1 L`1�r�'�� F �y�.' +` �'"� � i r � � ��I � y�t1 � I'` ��G�. 4� .� <br />4�f}�� � � ; ? � r�� r�� � � � / � <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 60Q hours in s�ccessfufly completed course worlc as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous ssage therapist license that was revolced, suspended, or not renewed? <br />Yes No If yes explain in detail. <br />License fe� is 75.00 <br />Make checks payable to Ctty of Roseville <br />� <br />�� <br />