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� <br />� <br />���� �. � <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />�6�1� 79�-r�3� <br />- Massage Therapist License <br />New License � Renewal <br />For License year ending June 30 ,� ��% <br />1. L,egal Name �l[ � �r �'!� }` J �O�-rhJ ..�' � 1��„��r� <br />2. HomeAddress .�w � { ff�AFV F <br />3. Home Telephone <br />4. Date of Birth - <br />5. Drivers License Number <br />6. �mail Address <br />7. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes _ _ N+� _ _ If yes, list each name along with dates and places where used <br />8. Name and address of the licensed Massagc Therapy Establishment that you expect to be employed by. <br />������ �r� ��� �� /'lt ?'fi y' . L. L. c: <br />9. Attach a certified copy of a diploma or certificate of graduation fro�n a school of massage therapy <br />including a minimum of 600 hours in sucaessfi�ISy completed course work as described in Roseville <br />Ordinance ll 6, massage Therapy Establishments. <br />�Q. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes ��_ — If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to Ciry of Roseville <br />