Laserfiche WebLink
_�;_ ; i � <br />� � � <br />� <br />Ffr�a�rr�� Department, L'a����� Dgva���n <br />2660 Civic ��ra��� Drive, �o�evi���,1�I� �5�.�.3 <br />(651) 792-7034 <br />Massage 'Th�ra��s� �ic���� <br />�m�s��o,s � .r"`�= r"' <br />. ic i u�w <br />New License Reiiewal !� <br />Fn� :.� eci�s�_ ti�ca� C_ il:l7�' lL'R� �� ���,. <br />L 4` - <br />�I'- �� ��� !� T '� � � <br />� . �:C��I� �i�lll7 +� S <br />,- - -- ._� ti . <br />2. I-iome Address� . <br />3. I�oi��� Telephone- <br />4. ��tc of Birth — -- <br />5. t3ri�ers License Number+ <br />6. �ta�ai{ Address <br />� _y .�ill ' —• -.. , 5 <br />7. I I i�� y� r.� ��.41�r t:�;:� I �,,� lat�� n I� .�,���� � 1��= �n} name otl�er than the legal �tan�e given in ttt�t��:U�►• i above? <br />If yes, list eacl� na�rte along with dates a�id places where used. <br />$ V� ti `L�r�d ;�'�i� a� d7se� r���s�r.d !4{, �g� T ji��gy E. �, I lh ���tr �tc� to plo i � I��.', 'V '� <br />��� � 4 � l_�'� •L 1� � ���_ �i L.�C, �� � 1�' � �� p. <br />R <br />9. Att�c11 a certified copy of a diploina or certificate of graduation froin a school of massage therapy <br />including a��nit�iinu�a� of 6001zours ii� successfully completed course wark as described in Roseville <br />Orditlai'�ce 116, ►-nass�►ge Therapy �stablisli►ne�3#s. <br />[ Q. Have you I�ad any previt��.4 _r' sa � therapist license that was revoked, suspei�tied, ar i�ot renewed? <br />Yes �'�� If yes explain iis detail. <br />� <br />License fee is 75.00 <br />Mal<e ct�ccks payable to City of Roseville <br />