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��� � <br />��� � � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55ll3 <br />(651)792-7034 <br />Massage Therapist License <br />New License Renewal �. <br />For License year ending June 30 �?� <br />1. Legal Nan�e �� �� � � �� Y� i, �: �' � `_�;�i.r �, � ti <br />2 Home Address_ ... , _ <br />��� _� a � _ <br />3. Home Telephone ' -- _ <br />� � <br />4 Date of Birth <br />5 Drivers License Numbt. " _ <br />�. TnsasZ A�drts's <br />— � I "5 • ,�r <br />�� _ � � _ <br />��R <br />�. Have you ever used or been knnwn by any name other than the legal name given in nu7nber 1 above? <br />Yes No lf yes, list each name along with dates and places where used. <br />�. ;.f.�� w: �ws i�tlf•_�sy „E �l� l�tcis�d �r1 a���ti• 7'1:�r,���F �.;�.�Sl:shment that you expect lo be ert�� ad �r, <br />� �+ �1.}ii �r;-+`c �+� �� .,� i k.r�� �::�.�� �.' MI `� +��� ��' {ti �'� � <br />� <br />{., �� � , � �' � a� <br />9. Attach a certified copy of a diploma or certificate cf graduation from a school of massage therapy <br />including a minimum of 600 hours in successfuily completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10 Have you had any previous. —wage therapist license that was revoked, suspended, or not renewed? <br />��c� ___ — N o— lf yes explain �n detail <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />