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�� �1 � <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 r� .� _ � <br />— Far License year ending June 30 ���r�+�.� <br />— l. LegalNa�ne �-ir���t: � ������r."�� %���.°�?�x ���� <br />— r� � . � <br />— 2. Home Address_ <br />3. Home Telephone- <br />4. Date of Birth <br />a <br />5. Drivers License Number <br />6. Emai1 Address — 't <br />7. Have you ever used or been known 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 places where used. <br />S, Namei ;��u},�: address of the licensed Massage Therapy Es�ablishment that you expect to be employed by. <br />,�at.� � �C*Jx -�j[���—�—r1�k�1��—�+r�'fY; coc'.����f--f*��CL�+��f. ���� i S%/_7 <br />9. Attach a certified copy of a diploma or certi�cate of graduation from a school of massage therapy <br />including a ininimum of 600 hours in successfully compteted course worfc as described in Roseville <br />„ _. <br />Ordinance ll 6, massage Therapy Establishments. <br />� <br />10. Have you had any previous *r• sage therapist license that was revoked, suspended, or not renewed?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 />