Laserfiche WebLink
�� ��� � � <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 />r>t �� tr• �? <br />For License year ending June 30 <br />' �. <br />I . L _�4�� !���i7r ' ' . � r' �' , r i `� � • , r I <br />r � <br />' 1 hyvi� •'�ticlr4�cx - • • — - - , � � �+ � <br />' ' � ' <br />3. Home T�Iephar� <br />4. Date of Birth <br />5. Drivers License Number <br />6. Email Address <br />7. Have you ever used or been lcnown by any name other than the legal name given in number 1 above? <br />Yes No Ifyes, list each name along with dates and places where used. <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by <br />9. Attach a certified copy of a diploma or certificate 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 />10. Have you had any previous massage therapist license that was revolced, suspended, or not renewed? <br />Yes No If yes explain in detail. <br />License fee is 75.00 <br />Malce checics payable to City of Roseville <br />