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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 />� <br />New License <br />For License year ending June 30 <br />1. Legal Name ��,� �.�,_� [ <br />,r <br />2. Home Address �_ <br />3. Home �"elephonE <br />4. Date of Birth <br />5. Drivers License Number <br />6. �mai1 Address— <br />Renewal <br />�`�-` % <br />� <br />.� , <br />L� <br />�_ �1a4�� �r ni ti7r �.c= ��:��ne other than the legal name given in number 1 above? <br />�'L:x ?���� :!' yes, list each name along with dates and places where used. <br />8. Name and address of the licensed Massage Therapy Establishmentthat you ��;t:t�� �.� � 1 �� t�� �,��'.�5•v�11 ��� <br />rr � 'i I r � {i ,i � ' y <br />� rl ��: ti. I _�7u� _}ti _y_4 I � .•.i -L+v ? 4. F i k. � L-.�_• �• L; � • � � I � - �'4* �f ��� I i -r <br />Ir -•�4 _� f + i . .ik_ ����v,.i.h� __ L'+� _ y: � <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 worlc as described in Roseville <br />Ordinance 116, massage Therapy Establisl�ments. <br />10. Have yo�_ �■�-� ��i r�r ���,t� ,:, �•�• erapist license that was revolced, suspended, or not renewed? <br />�� _„_ � �'� � _ If yes explain in detail. <br />License fee is 75.00 <br />Malce checics payable to City of Roseville <br />