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2006_0710_Packet
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2006_0710_Packet
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� " rY <br />� <br />j#�li'h7 � � <br />� <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 30 !_ t~ { r � <br />. �— <br />' '� , � <br />1. Legal Name .� .{;�j ir GtiL4����_��•" — <br />�, <br />, . ' :�fr�f <br />2. Home Address _..... <br />i � ,. <br />3. Home Telephone <br />4. Date of BirC� . — <br />5 Drivers License Number <br />6 Emai1 Addresr <br />—, _ .,v���- <br />r <br />i� . .r F - - • — , � <br />� <br />• . _ <br />7. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes __ No If yes, list each name along with dates and places where used. <br />�. �=,i •: it .0 i.it�•J: � k� •. Fthe licensed Massage Therapy Establisl�an� i that you expect to be employed by. <br />������'��;�y�-�tpt����r� ��� r,l�+;�_� ��f �, �—�'���,f_�L 41�,•����'— ���' �— <br />.} � 1 � <br />9. Attach a certified copy of a diploma or certifcate of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course worlc as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />�p, Have ��•�� h�r+ anv previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes ��'• , _ If yes explain in detail. <br />License fee is 75.46 <br />Make checks payable to City of Roseville <br />
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