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� 4 � � . � <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 />� --- <br />For License year er�ding June 30 �� �'� � <br />r T <br />I. �.egal Name �_1,�,_� l'�C] 4 �����.1 ��� � �� <br />2. Home Address. � ..� ... <br />3. Home Telephone � �� <br />4. Date of Birth <br />, <br />5, Drivers License Nut�ber <br />6. Email Address <br />7 F lak� kt�u 4e� ��d or �c� known by any name other than the legal name given in number 1 above? <br />Yes � Nv .� If yes, list each name along with dates and places where used. <br />— � -�.- <br />$. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />`I'''1w r. ���:ti_� � �.�b�� � 7�t� � g.�:; �L ����'* �''�r <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 su�cessfi.illy completed course work as described in Roseville <br />Oi-dir�ance 116, massage Therapy Establishments. <br />10. Have you had any previous.�uassa�B therapist license that was revoked, suspended, or not renewed? <br />Yes No If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to Ciry of Roseville <br />