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���� � . .--. � , � �_ J <br />Finance Department, License Division <br />2660 Civic Center Drive, Rose�ille, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License f�r.� Renewal <br />For License year ending June 30 �c; �'I- <br />1. Legal Name _ � f� 4`• �l � � �hti r �� : `�i �� <br />2. I�om� Address <br />3. Home Telephone <br />4. Date of Birth <br />5. Drivers License Numb <br />6 Emai1 Address <br />7. Have you ever used ar been k�ax�n 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 />8. Name and address of the licensed Massage Therapy Establishmentthat you expect to be employed by. <br />..:}f-a G2 Cat-� ��� I�� �.4h 5�=i.s-s-1� 1 � � �"J \j�(. Lt�k T �,�7_���� � 1\7�.1 � ��St^-!� i'�{�h� �] i_Z._�.�} i�'1�} .�7� � 1 � <br />9. Attach a certified copy of a diploma ar certificate of graduation from a school of massage therapy <br />including a minimum of G40 hours in suecessfulIy completed course wark as described in Roseville <br />Ordinance ll 6, massage Therapy Establishments. <br />10. Have you had any previous �nassage therapist license that was revoked, suspended, or not renewed? <br />Yes No If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of ftosevill� <br />