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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 Lice�se year ending June 30 <br />�! <br />1 Legal Name ��� ��] i�`� I�r'� � i <br />2 Home Address <br />3 Home Telephone_ <br />4 Date��f�3irth� <br />5 I�rivers License Number ` <br />6 Emaii Address . . . . , _ <br />7 Have you ev�- used or been �uown by any name other than the legal name given zn number 1 above7 <br />Yes No • ff}�e�_ list each name along wx#h dates and places where used <br />8 Name and address of the licensed Massage Therapy �'skabl�sY�tn��t that you expect to be employed by <br />r�c��� �41-��.l1� �,�:r�� ���. �;�3;__,I(�5�' r�� BZ R���,��Il�. ��i��,' s <br />9. Attach a certified copy of a diploma or certificate of graduarion from a school of inassagc therapy <br />including a minimum of 600 hours in successfully completed course work as described in �oseville <br />Ordinance ll6, massage Therapy Establishments. <br />10 Have you had any previous massage therapist license that was revoked, suspended, or not renewed7 <br />Yes — �1' — If yes ex�lain in detail <br />License fee �s 75 00 <br />Make checks payable to Cit� of R�osevilte <br />