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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 License year ending June 30 <br />� � <br />T. T r��,l �,r-r,r ���-��_�- � � �{ #�� �� � <br />..-----...._ _ .. <br />, � • -•-•----• . <br />2. Home Address <br />3. Home Tele�hone � .,,� � <br />4. Date of Birth <br />5. Drivers License Number <br />6. �mai1 Address <br />7, Have you e��°� used or been �. �• •�{i_ by any name other than the legal name given in number 1 above? <br />i'�5 _ ;�:� �� If yes, list each narne along with dates and places where used <br />�$_ � r��. �ua ��;;ess u� �:^ ;;-�r.s�l 7�•f:.��'.ge Therapy Establishment thatyou exr�ect to be e ��•rc[ by� f�� <br />������r �� �_ r � �-{. � � �� rr 3r � ��_���p' � <br />� �_.�- � -��� _� � � �'�� d l � <br />9. Attach a certified copy of a dipCo�na or certifcat�e of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any pr�•.:�,�s �,_a.s. �t therapist license that was revoked, suspended, or not renewed? <br />Yes �11� �� If yes explain in detail. <br />License fee is 75.00 <br />Malse checks payable to City of Roseville <br />