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New License <br />� ��� <br />�. <br />Finance De�vartment, License Division <br />2660 Civic Cent'er Drrve, Rosevitie, MN SSll3 <br />(651) 792-7034 <br />Massage Therapist License <br />Renewal �r' <br />For License year ending June 30 ,�,�'� <br />1. Legal Name ��r� ti �x'7 �� <br />' ' , . ;�,,., �� . ,— _ <br />2. Home Address <br />3. Home Telephone <br />4. Date of Birth <br />� <br />5. Drivers License Number <br />6. Err►ai1 Address <br />r � <br />., �_�� <br />� <br />7. Have you ever used or 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 li 5ed �[assage Therapy Establishment that you expect to be employed by. <br />�-� �� ���� <br />� r]R�5_k���. 7'�� �i�� � � �k�X � " i`-.� _��YV 5 5 V. ��i \� � � l � 3 <br />-��� Z.7 <br />9. Attach a certi�ed copy of a diploma or eertifica e ofgraduation from a school of massage therapy <br />including a minimum of 600 hours in successfuliy completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous rn sage therapist license that was revoked, suspended, or not renewed?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 />.� <br />