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�� � � <br />���� <br />Finance Department, License Division <br />2660 Civic �ea�er Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License Renewal . � <br />For License year ending June 30 �-da � <br />1. LegalName �� : �i,•-�r��` �'j�� �_�;f:�x,���. <br />2. Home Addre� <br />�. , <br />3. Home Telephone ' _ <br />4. Date of Birth , r- <br />5. Drivers License Number , . <br />6. E�naii Addr � - - --.— <br />w <br />7. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes �_ No If yes, list each name along with dates and places where used. <br />_ � F <br />____ _ _.. � I _•_ <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />4�'��N�� '.� {�'���� i ��� hf �'� (� T� �'n� ��- 5�f l� <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 wark as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />73er No If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />