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1����� � <br />.�� � � <br />F�nance Departmen�, License Division <br />2660 �ivic Center Drive, Roseville, MN 55113 <br />(651) 792-7034 <br />rViassage Therapis� License <br />New �,icense Renewal � <br />Far License year ending ,Tune 30 -�t'l � � ' �-�E' �' <br />l. �.e�al Nan�e �.�o ��NNr% ����� o_ �cif�-�r_,��.-- , <br />� ,. . . <br />2. Har�ie <br />/ � <br />3. Honae Telephone_ <br />r: / _ r <br />�. Date of Birtli <br />_. _ r . , . <._- _ - �- , , , �, <br />5. Drivers License Number,�, _ , . -- . - ..,.... �s, , _ <br />6, E�lai] Address <br />7. Have you ever used or bee�3 known by any name otlier than the legal name given in number 1 above? <br />Yes No _ If yes, list each name s[ong with dates and places where used. <br />- - ,• - - .. ' � <br />8. Name and address af the licensed Massage Therapy Estabiishment tha}t you ,e-x� ect to be employed by. � � <br />`�; v{�� +J �� .:7 i!? `�. �l�r � J i I Z t-j a �'� ,�`� LtJ (�U•=� r' f i f.-�� �f� �lJ .'7 �j r I j <br />� <br />9. Attacl� a certii€ed copy of a dip[oma ar certificate of graduation from a sehoal of massage therapy <br />inciuding a minimum of 50D hours in successfully completed course work as described in RoseviIle <br />Ordinance 116, n7assage Thera��y Bstablish�nents. •�n� ���u <br />I0. Have v�u had any previot�s massage therap€st Eicense that was revoked, suspended, or nat renew�d? <br />Ye:. No __�_ If yes explain in detail. <br />License fee is '�S.flO <br />Make checks payabie to City of Rosevilte <br />