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�� � `'1 <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 License year ending June 30 <br />l. i,a�a: Ti$in.� ����� M�� �� �+'�,C+� ��tic�i � �r � ���.`� ����� ti <br />�.. Home Address _ _ <br />_ � <br />.. Home Telephone <br />�. Date of Birth <br />�. Drivers License Number <br />d. Etnail Addres! <br />r��— <br />� <br />, Have you ever used or been ks,n.x�� by an�y name other than the legal name given in number 1 above? <br />�'cs ��' _, _ If yes, list each name along with dates and places where used. <br />R. Nau�e 8n� B�Jrezs �Ftli� fi�er�zed T4iAY �e TTiec�p}• Fsl�hlj�hrr�nl Gha� �r,�i er�p�p ���mpf�y�d b}'. <br />�,s,�� � �.�`�+ c� ���� . _ ��1.��i�. �r�_ �S�' �1 r-,��� t�� <br />I � �'.' � �-�.Yr� �'or-� � �.r� �- <br />�.��i47'�� ��� t���r� <br />. �. �t�ach a�e�i��� �t7p�r ��a di�r]�trla 0� c�evtli�c�t� �f�1�4�iAll�[1 f�ri a� schoo� o�m� kFxrap� <br />. �.'�,.... r � <br />:;: a��li�iL;:z ��•rrniirih� �,; A{�D h�u�s ir1 s�r���al�ilJfy oaRrip3�ir�i r.vursc w�rk e� d�acr��ad in R,oxxilJc <br />` �rd�rm�-� 1 I� mas���c Fhcrap}� �$blishmcnt� <br />10. Have you had any previous rnassage therapist license that was revoked, suspended, or not renewed? <br />Yes ��— �._ If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />