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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 />New License Renewal <br />For License year ending June 30 ��� � <br />1. LegalName_�� � j ��� �-r� , i. �. �� 1�'k� �`� <br />2. Home Addret <br />�r <br />3. Home Tetephats,. <br />4. Date of Birth y�' F � <br />S. Drivers License Nurqb4. _ <br />6. �mail Address <br />7. Have you ever used or been k_ u��.� 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 piaces where used. <br />$i �a�� :�i ad�l��<x nf the licensec �FT�� �S: Therapy Establisl�ent tt�t you expect •:� be employed by. <br />� �'� � � �� ''�•�: � �u L :� �— r'� �' �� f� (_.�? �C , ����a n �a � �c_ -. <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. Have you had any previous �as�ge therapist license that was revoked, suspended, or not renewed?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 Roseville <br />