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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 />New License � Renewal <br />For License year ending June 30 � <br />•i <br />I �.e:r,ii'�':,ir�:}����� � <br />� ..n <br />I ' <br />''. Home Address, _—_ <br />f J <br />. . � _ "7 <br />a Home Telephone _ . � <br />-� � � <br />�. Date of Birth _ <br />5. Drivers Lice�lse Number� _ <br />h <br />;: E�xiail Address <br />���. <br />;. Have you ever used or been kn�wa7 by any �xn� other than the legal naine given in number t above? <br />Yes No — If yes, list each �arrc alo�ig with dates and places wl�ere used. <br />$.•- �4 �. �; � r.;.�'.. �� �� Therapy Es ablislune�zt that you expect to be e€nployed by. <br />.1 � �,� � _ � �_ t �����..,.��:�� <br />9. ACtac11 a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />includiz�g a�nini���urn of 600 hours in success£u1�y completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />14. ]����: ;;•�. . i.���7gc therapist license that was revoked, suspended, or ;iot renewed? <br />Yes � �L• <br />If yes explain in detail. <br />Liceiise fee is 75.00 <br />Mal�e checl�s payable to Ciry of Raseville <br />