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��� � <br />��� . � .� <br />Finance Devartment. License Division <br />2660 Civic Ce�ter Drive, Rosevilie, MN 55ll3 <br />(651) 792-7034 <br />Massage Therapist License <br />New License <br />Far License year ending June 30 <br />1. Lega1 Name�'Ff, r L, L ti z- <br />2. Home Address— <br />3. Home Telephone j - • ,,,,, <br />4. Date of Birth <br />5. DriversLicenseNumbe. <br />6. �mail Address <br />Renewal � <br />, .J�1 ti � � c" � : � <br />7. X�ave you ever used ar been known by any name 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 />8. Name and address of the' lic�enseJd <br />I��'�. 5 � f� <br />Therapy Establishment that you expect to be employed by. <br />,�j�a L.}f <br />9. Attach a certified copy of a diploma ar certificate of graduation from a school of Enassage therapy <br />including a minimum of 600 hours in successfully completed course wark as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes t" �. If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />