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����� �� <br />��r <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 />� <br />For License year ending June 30 ��- �i C% <br />�, c <br />1 Legal Name___���� ry����� ����� � � �J�� � <br />2. Home �,.ddres5 <br />3. Home Telep�or�e_ <br />0 <br />4 Dale of Birth � <br />5. Drivers License Number� <br />6. Email �ddress <br />� � � �� <br />x <br />7. Have you ever used or been known by any name other than the legal name given in i�urr�ber 1 above? <br />Xes _...__..... No ; If yes, list each name along with dates and places where used <br />$�;inie �n� ;idt[r4�< � ��'�ti 1 it ;;-�rtc? Massage Therapy Establishment that you expect to be employed by <br />�����Y � � � � ��i�--�r��Y� %G.� �� r �'r r r�1 ����� ;.#�,z ./�'� �[r' <br />J3`11�j <br />9. Attach a certified copy of a diploma or certificate of graduarion from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance ll6, massage Therapy Establishments. <br />10. Have you had any previon� �assage therapist license that was revoked, suspended, or not renewcd: <br />�. <br />�'e-�.._ _—_ .— N� �, If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />