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�� ���r� -r � <br />���� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License � Renewal <br />For License year ending June 30 <br />I . Legal Name � � i 4 C'. � ��. �,��Cx_.� � �"7 �_ ���� 1� �� � �� -1T <br />2. Home Address, <br />�, <br />3. Home'Celep4�one_ <br />4. Date of Birth <br />5. Drivers License Number . ���, 4.,, , , , � � <br />6. Email Address- ' — — <br />� <br />7. Have y o eve� used or been lrnown by any name other than the legal name given in number I above? <br />Yes No If yes, list each name along with dates and places where used. <br />$. Name atad address of the licensed Massage Therapy �stablislirr�eirt that you expect to be tnl�iogx�5 b�', <br />�c,�c�:�i. c�,� -z �.� lt�-� �.�rs,-� '`�1fa-��.� � ���a ���-'1��. � �v�t?_ 1�-r�� . ��k���+�� �+�'�- �`�� � � � <br />9. Attach a cEEtifiec� copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 6001iours in successfuEly completed course work as described in Roseville <br />Ordinance ll6, massage Therapy Establishments. <br />10. Have you [�ad any previous ssa�e therapist license that was revolced, suspended, or not renewed? <br />Yes ��' �.._.�. T� yes explain in detail. <br />License fee is 75.00 <br />Malce checics payable to City of Roseville <br />