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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 />1_ Legal Name_� � �'� f � � <br />� <br />2. Horne Address . �- Q t A � �,..! <br />- *" +� . � � <br />3. Home Telephone �. : . <br />4. Date of Birth <br />, _ ... � J... . ,... , . , <br />5. Drivers License Number <br />6. Email Address— <br />� <br />7. Have you ever used or been known by any nart�le 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 />� � � � � � <br />� �- <br />-, , � , ✓ <br />8. Name and address of the licensed Massa e Th�rnE� F.,��lal iyhinent that you expect to be employed by. <br />��� � a .� � � � �7�-[_� �.�[ 1�. - __�_�__'�a � �, �� t�; SS t �. � <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 />�p, Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes �'' , If yes explain in detail. <br />License fee is 75.00 <br />Mal�e checks payable to City of Roseville <br />