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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 Licensc year ending June 30 �-{��� <br />1. Legal Name �'�, ���� r� x L+'� ����:�• <br />2 Home Adc€ress. rY, <br />3 I�Tarne Telephone_ _ <br />4 Date of Birth — <br />i r <br />5. Drivers License Number <br />�i. F.:17ai7 Jti��lresc� _ <br />7 Have you ever used or been knqwn by any name other than the legal �arn� given tn number 1 above? <br />�'•rti _ . �'i ��� If yes, list each name along with dates and places where used <br />8 N me and address of the licensed Massa e The p}••����r��•� �� that you expect t� be empfloyed, hy <br />-� ��t�6.LJ�.�, ��� i �Y�' � F� i•'��: T� TrfLf.r r� I--�f ��• F' I f�� ��� �,? <br />� � G € � •, .�'_� �'1 '.l `� �l <br />9. Attach a certified copy of a diplen:a or certificate of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous n�assage therapist license that was revoked, suspended, or not renewed? <br />Yas __ — No � 3.— If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />