Laserfiche WebLink
� � <br />��� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651)792-7034 <br />Massage Therapist License <br />��� <br />� �C'r� l.i �4�:o-C r <br />� � =�-- = Renewal <br />For License year ending June 30 ��_ :� <br />1. L�ga� T�fliruc :�, �'_ �, c . (� . �: f� ��s.�. � (� �-- � �Y' ( 9l� � �-� • � �� i� � _ � � I � . <br />2. Home Address. <br />3. I [•_�nw Teleplao€__ — <br />4. Date of Birth <br />5. Drivers License Num��, <br />6. Bmail Addres _ . <br />P�I�� <br />� <br />7. Have you �:�'er used or bcen k��own by any name other than the legal name given in number 1 above? <br />Yes _' �- �� ___ _ If yes, tist each name along with dales and places watere used <br />� <br />�����` � 8. Name and address of the licensed Massage Therapy Establishment that you expect to be ��p e�l k�}'. <br />' `� ` ���'�� F L_� J� j �. �)_�,�� [. �!: �-�I•� ��=':s,��'L� v'• r r ` �. �'�.�c f. �—,:�—�. � �t i.J ��+-� � � GuS ,�� <br />._. � � •. � <br />�k-}; .�'-�+�'� �' i •'�� f'�,'`, <br />ssrr3 <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 work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revolced, suspended, or noL renewed? <br />Yes No �'�'1�L7 If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />