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New License <br />� ���. 1 <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />Renewal <br />For License y�ar ending June 30 <br />I . L.�gaa T�ain� ����ti'��. _ �. <br />�. Home Address� <br />3 Home Telephone _ <br />.� �_ I— .. <br />� Date of Birth <br />5 Drivers License Number— � � <br />6 �mail Address <br />, 3 _ <br />.� ���. <br />�. <br />_� � I <br />_ � <br />�. Have you ever used or been �ow� by any name other than the legal name given in number 1 above? <br />Yes T� �_ _ If yes, list each name along with dates and places where used. <br />., <br />�, � <br />8. Name and address �f 1bx 1-��is��! 1�d��age Therapy Establishment that you expect to he employed �- <br />� � r�� � + �+� - � .��.��—� � �� �i� : � � � � � <br />9. Attach a certi�ed copy of a diploma or certi�cate of graduation from a school of massage therapy <br />including a minimum o f 600 hours in successf�xily completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. � � . �.� ��� f� , � � � �� � <br />10. Have you had any previous rna��e therapist license that was revoked, suspended, or not renewed?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 />