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� �r�� � � <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 <br />For License year ending June 30 _ <br />�. ��C471F �i�Fl� `�� l �r <br />2. Home Address <br />3. Home Telephone __ <br />4. Date of Birth <br />5. Drivers License Number <br />6. �maal Address <br />� <br />Renewal <br />� F.• t� f <br />.•� �•�L'���� <br />7. Have you ever used or been lcnown by any name other than the legal name given in number I above? <br />Yes No If yes, 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 />Make checks payable to City of Roseville <br />