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��� � ._,�,�� <br />� <br />Finance Departmen�, License Division <br />2660 Civie Center Drive, Roseville, MN 55113 <br />(651) '�92-703� <br />Massage Therapist L�cense <br />N�w Licensa Renewal a�� <br />�. ,, .,...._ <br />ror Lieez�se year ending J�me 30 ���`/� <br />1. Legal Nanae �? �-� � �:� �i �.� �' .� �-C'� �' �, <br />2, Ho��e Address ��-- > � <br />3. Home Telephane <br />4. Date af Birti� _,_ - t�°� <br />5. Drivers License Nwnber <br />6. Eznail Addreas �, <br />7. Have you ever used or bee�� known by any name other tl�an tlie legal nazne given in number 1 above? <br />Yes , ,_ No Ifyes, list eacl� ��a�ne alang witli dates and places where used. <br />�__a �, <br />8. Na��-�e and address of the lice«sed M <br />R �` � � i�,r�,fl,tv�.. ,�:-i. <br />Establishme€it #�iat you expect [o be emptoyed by. <br />�#� 5 S�i i S <br />�_�-•.�-� �-_5 v"'ti r � c"sL' � �-..!C� `'-t.s'�_ <br />9, Attacl� a eerti�ed copy oi a diploinl or certificate of grad�ation fro��� a school of inassagc tl�erapy <br />includiz�� a n�iniinErm of 600 hou�s in successfiilly coznpleted course work as dascribed in Roseville <br />Ordinance 116, massage Therapy Establish�nents. <br />10. Have vou had any previous masslge therapist lieense tl�at was revofced, suspended, or �3oi renewed? <br />Yes No _'" If yes explain in detail. <br />License fee is 75.00 <br />Make cE�eelcs payable ta City of Itoseville <br />