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��� �� <br />���. <br />Finance Department, License Div�sio�. <br />2660 Civic Center Drive, Roseville, �d 55113 <br />(651)792-7034 <br />Massage Therapist License <br />New License ��i���� � � � � � d � � <br />For License year ending June 3���%� �`�_ <br />I. iyegal Name ���� �� � <br />° - � r -- <br />2. Home Address <br />3. Home Telephone — <br />4 Date of Birth ' <br />n � �_ , . <br />5 Drivers License Number <br />6. EmaiL pddress <br />7- Have you ever used or been known by any name other than the legal name given in number I above? <br />Yes _ _ f�FO _ _ If yes, list each name along with dates and piaces where used. <br />S. �+�7.�� and ac�dr��s of e.6r ]�yc�saed �lass.i,� 7iYera�y� �bl"ss�eni, tha�u e��ect t� em�?lo�� �� <br />� �,t� ����� M r� _. z 2 _ � LL, � �` � <br />�� %� � ���� <br />9. Attach a certified copy of a diploma or certificate o f graduation �'o�n a school of massage therapy <br />including a minimum of 600 hours in successfully complete�� �o� work as described in Roseville <br />Ordinance I 16, massage Therapy Establishments. �� �� <br />I0, Have you had any prf- ---- °- therapist license that was revoked, suspended, or not renewed? <br />Yes �� �•- Ifyes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />