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�� -'� � <br />��� �. � <br />Finance Depart�en�, 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 />L LegalName ��i��� � ��l I� �� ��� <br />2. Home Address ' u . . . �� � <br />r � n r--, � ,. �' � � i �� <br />3. Home Telephone <br />— � �� <br />4. Date of Birth <br />5. Drivers License Number <br />� " <br />6. Err�ail Address— <br />� �+ � <br />� <br />.�- C>7 <br />A <br />7. Have you ever used or been knotu� by an}- name other than the legal name given in number 1 above? <br />Yes �* �- _�_ If yes, list each name along with dates and places where used, <br />R. �+Tni�ie �r3 <br />� ���.�L�.. <br />�rf �hu a�co��ed Ma�age Therapy Establishment that you expect to be employed by. <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 successf�lly 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 Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes ��' .�'— If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to Ciry of Roseville <br />