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����� � <br />�r � - — � - — �— �— � <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 1� <br />For License year ending June 30 �� ��'� �. <br />1. Legal Name ���? � - �'���i �' <br />� �� �� �� <br />i�� '�" 2. Home Address *�'���L.� ,_� I�� <br />3. Home Telephone <br />4. Date of Birth _ <br />5. Drivers License Number <br />6. Email Address <br />7. Have you ��,<< ,I:� � or been ki �ot F�' any name other than the legal name given in number 1 above? <br />��'� __ No �� — If yes, list each name along with dates and places wl�ere used. <br />8. t���o s�:� �ddr��s r�f d�e �iUeri�ecJ Mua��'���ap;+ �sl�bli�hn:ti�t 1f�st yo� exp�� W be �rnplo}��d Fr��. <br />.. 1���" ��� +��� �'S � � �,� �'��'1�`�� � <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 success�zl(y completed course work as described in Roseville <br />Ordinance 116, massage Therapy Estabtisllaner�ts. <br />10. Have you had any previous ir_is ,i�fi therapist license that was revoked, suspended, or not renewed? <br />Yes No If yes explain in detail. <br />r�� .. �� <br />License fee is-'�5. 0����� 5�� <br />Make checks payable to City of Roseville <br />