Laserfiche WebLink
� ��'� � <br />� <br />Finance Depar�tment, License Division <br />2660 Civic Center� Dr�ive, ���e�fi��, MN 55113 <br />(651)792-7034 <br />���s���� Th�ra�i�� i�ic���s� <br />New License <br />Renewal <br />For License year ending June 30 <br />.� ��r , <br />` r�. � '�~_�� <br />1. i,egal Name_�! �_� ��� f <br />., <br />,� <br />r-. _ . � --- r- _ ._ _ <br />2. Home Addres� �:� <br />A - � <br />3. Home Telephone _ <br />4. Date of girth - <br />5. Drivers License Number- <br />6. Fina"sL ��J=t �r <br />� <br />a <br />7. Ha�e you ever used or been known any name other tha�� the legal name given in number 1 above? <br />Yes ..�. No If yes, list each na�ne along with dates and places where used. <br />S. T� a�i1e a�id �.�,'�rrl rrs� � �f i��� 1;*�sr�.{ �f 7s-�age Therapy Establishment that you expect to be employed by. <br />� ti i r� �`���s J� .�r � �. <br />9. Aitach a certified copy of a diploma or certificate of graduation frarr� 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. Ha�e you had any previous mass <br />Yes No <br />License fee is 75.00 <br />Make checks payable to Ciry of Roseville <br />therapist license that was revoked, suspended, or not renewed? <br />If yes explain in detail. <br />