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�� <br />. <br />� <br />���� � ' <br />�- <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55ll3 <br />(651) 792-7034 <br />Massage Therapist License <br />New License �k Renewal <br />For T.,icense year ending June 30 �� <br />1. Legal Name _ _ �r���'1t i i; y P_ r�4i4�j �, <br />� <br />2 Home Address– <br />�� <br />3. Home'T'etephonf _ <br />4. Date of Birth <br />5. Drivers License Number— <br />6. Email Address — <br />i � <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 />E. �1$ an3 sc��� �f iE�r l;ccr.std �in�ss�r TT��ap;• Fsia}�1��1;n�Lr.� that you expect to be rr. � 1nti•v� bF _ <br />— ,������-��'� ,.,�� ��53 ���5�, �'��'��y��t,����ae�, �S � �,�� <br />��.��.�. �����f, •� <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 work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. I-�ave you had any previous ��sage therapist license that was revoked, suspended, or not renewed? <br />Ye5 No � If yes explain in detail. '" <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />