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�;�� � � ' <br />��� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />�,:,. <br />�� <br />, <br />New License Renewal <br />1 or =iten�u w�*nr ��r,ding J�r_� ;� "� �� r ✓ �i_r � � �- f� w <br />f7 . <br />�. LC�y'A� �If�IC . ' r ��L '�• L�� �.� �, t_ <br />2. Home Addres�. �- . . �,� _— . <br />3. Home Telephor�� .. _ " <br />4. Date of Birth ,��_ .. � � ,� <br />f • -- � <br />5. Drivers License Number, _ . . _ _ _ <br />. Y r <br />6. Email Address � - •; _—, ,��r <br />7. Have you ever used or been f��� �}+��� by any iiame other than the legal name given iii ��u�z��ar 1 above? <br />Yes � o_,,, _ If yes, list each name along with dates and places where i�set[ <br />� N�n:;; �i_7J :,cl I� ca� ut� I I� Li�ns^d �i,�s;:,�c 'L F�4��it�rr E:�labl ishrn fit 117�1? � OL =}:�7�� L' e�n:��k�� �y <br />�[,r�'_�-..�`��;�. �.? a � t� �s��'S�����:�� � d �����'.:��_ i�`T�— <br />q� , � ,. <br />�Lx�•]['; ,�� 5• t� r��-?:�..� i�� � 5� <br />9. Attach a certified copy of a diploma or certificate of graduation froin a school of massage therapy <br />including a iuinimurn of G00 hours in successfully completed course work as described in Roseville <br />Ordinance 116,massage Therapy Establishments. <br />I�. Have you had any previous �ti�.;�;L therapist license that was revoked, suspended, or not renewed? <br />Yes_ __ �� �, If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />