Laserfiche WebLink
��_�.r � .�� <br />� <br />rinance Depat-tment, License Division <br />2660 Civie Cente�• Drive, Roseville, MN SSI13 <br />{651) 792-7034 <br />Mass�ge Therapist License <br />\ � 1 f _ <br />id�esrs�� Rei7ewal X <br />For License year ending June 30 �.�� "[.��� <br />l. Legal Na��ie ��1�^l�'� ���'%1l�` ��� <br />2. Home f1�ic�ress <br />3. Home Telephnne______�._r_. <br />4. Date af Birtl� <br />5. Drivers License Num6er <br />�' <br />G. E3��ai! Address <br />.- <br />7. EIave yo« ever useci or l�eei� Icciowi� by �ny ��anze other tl�asi the legal nan�e give�l in number 1 a6ove? <br />Yes No .�,�..__ If ycs, [ist eacli ���F��e along with d�tes and pl�ces w.here used. <br />��,� �-�-- <br />8. �1a:1 �7�a dress af rI� ly�cnseci Ivia zge�er�py Estsib[islimet��tl�at yoti vpe�d° <br />� �� <br />°��d�PVr f/P�, � /�� � �'//3 �r� � �� <br />9. Attac�� a ce��tifsed copy of a diplo�ua or certificate o graduation from a scllaof of n�assage therapy <br />ii�cludi���; �1 minimt�n� of 60fl hours i�l successfi�lly co �p teci cot�e work as describe�n�ose 'ile <br />�. � <br />Ordinauce i 16, massabe Tlierapy Establisl�i�lents. ('j y�11 L (%V\ � <br />10. Have ����� ���' ^^" """'IOLiP ��•^c���� r��er�pist licci3se tl�at was revoked, suspended, or not renewed? <br />Yes a�o -. If yes expiain i�� detaiL <br />I <br />r <br />