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� <br />� <br />�� � , _, � � � <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 Zp�6 <br />1. L,egal Nzune �' ��� � - � +� 4� �1 � �'� <br />2. Home Address — <br />3. Home Telephone <br />4. Date of Birth <br />5. Drivers License Nurnb�__ <br />6. E�ail Address <br />l <br />7. Haee you ever used or been lcnown by any name other tl�an 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 licensed Massage Th � E�#ah�ishrnern tiiat ycrn �t ko bc emp�v;-rd b��. <br />�3vIF�Y .��# 5titi+1.. � p�+� � ��� � �_f� �r �1 � � r.��� �'� � � L �� �— <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 successfully completed course worlc as described in Roseville <br />Ordinance 116, massage Therapy Establisl�ments. <br />10. Haee you l�ad any pr������ therapist license that was revolced, suspended, or not renewed? <br />X�s �� If yes explain in detail. <br />License fee is 75.00 <br />Malce checics payable to City of Roseville <br />