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� � �� � <br />� <br />Finance Department,�License Division <br />2660 Civic Center Drive, Roseville, ��� 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />�C4Y �,ICCIISC �C]1CWt1� <br />For License year encling June 30 <br />1. Legal Name ���"� ����� ����'"� <br />2. I-lame Address. <br />3. 'in�.:�: Telephone <br />4, f�ate of Birth <br />5. Drivers License Nun�bei- <br />6. Emai� Address— <br />� <br />7. Have you ever used or bcen known by any �; �Y otl�ea• than the legal n7me given in number i above? <br />Yes No. _ If ycs, list each 21�m� along with dates and places where used. <br />8. Name �i�d address of the licensed Massage Therapy Establishment that you expect to be �«�P�ayed by. <br />—��-��--� +� —W'r�����• d_��+�t��• itil��.L <br />'�1�1 ��,:-C,v��. � ��� �5� �] � � ��� <br />�r�£� �ti��1 <br />9. AttFicla a ceri�fiec� copy of a diploma ar eertif�cate of graduation from a school of mass��;� thera}�y <br />including a minirnu��� of 600 hotu's in s��eccssfi�lly completed course worlc as described in Roseville <br />brdinance f 16, c�7assage Therapy 85tablishments. <br />10. Have vou had any previo�is massage thez•apist license tha't �vas revoked, suspended, or not rene�ved7 <br />Yes — �� _ :�yes explain in detail. <br />Licci�sc fee is 75.00 <br />Make checks p�y�ble to City of Roseville <br />