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�- <br />. - �� <br />�� � � - � � <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 />t <br />For License year ending June 30 _�i.y�'=�� <br />I C��r ii � 7i7:� _ ��7 � ��� � � 1 � � <br />2. Home Address L- - �- { <br />� — r, �, � ,-, <br />3. Home T�lep�ic <br />4. Date of Birth <br />_.'.�".�.�,__ <br />S. Drivers License Number -.. <br />6. Einail Address. <br />� <br />7. Have you ever used fi!' ':Len 1��• t�+�•�•. b:+� any name other than the legal name given in 3iuulber 1 above? <br />Yes �It� � If yes, list each name along with dates and places where used <br />8. Name and address #'fi�;� licensed Massage Therapy EstablisE�meryt,tl�at yq�� �]��ect t�a be e�a�1� to ed u� <br />��r'��—���'�_�fV `��1�. .f'���� �• �l � `�dr �.i.,. � Z�s�4rl� �.-��� ,.� <br />9. Attach a certifed copy of a diploma or certificate of graduation from a school of massage therapy <br />including a�ni��in3um of 600 hours in successfi.tEly completed course worlc as described in Roseville <br />Ordinance 116, massage Therapy �stablisll�ne��ts. <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes � U. 1f yes explain in detail. <br />License fee is 75.00 <br />Ma1ce checks payable to City of Roseville <br />