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.�� � <br />�v�� <br />Fzn � n��.� Deparkm�nt, License Division <br />2660 Civic Center Drive, Roseville, MN SSll3 <br />(651)792-7034 <br />Massage Therapist License <br />New License � _ Renewal <br />For License year ending June 30 ��� 7 <br />�% A �� <br />:. Legal Name fi, U% /� 1� �' ���-, ���,�� <br />2. Home Address c <br />3. Horne Telephone <br />4. Date of Birth <br />5. Drivers License <br />,.' ^ — <br />6. �maii Address <br />'�, Haue you e��,r used or been k�ow�1 by any name other than the legal name given in number 1 above? <br />Xr� _ _ No If yes, list each name along with �- ' ' ' � �' �� � -' <br />,� ,. <br />r — <br />8. Name and addresa � f�� 'rir�r�}r .�9�di�1 }•+ai� �xpe�t ���rriP�3^a � <br />��� � ���+.�._ ����� _ .. <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 success�'ully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />]�]_ �is�r�e ��: �� ; ..� �r���iou� ra.pist license that was revoked, suspended, or not renewed? <br />�'�_ _ N __ Ifyes explain in detail. <br />License fee is 75.00 <br />Make checks payableto City of Roseville <br />� <br />� <br />