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��r,,� �„ , <br />�,,�r� �1 .� <br />:.. »� _ ,� <br />Finance Depa�rtment, License Division <br />2660 Civic Cente�r Dri�e, Roseville, MN 55113 <br />{651} 792-7034 <br />Massage Therapist License <br />New License Renewal <br />For I,icense year ending June 30 ��� - <br />I. I,egat Naine �..Jw �:%.� �-v l} 2 <br />.�_ n . <br />2. Hoi�ne Address - <br />3. Hoine Telephone� <br />4. Date of Birth <br />0 <br />S. Drivers �.icense Number� <br />i n, � � <br />6. �rslail Address <br />7. Have you ever used or been known by any name ofher than th� legal t�ame given in n�unber 1 above? <br />Yes No _�� ° yes, list each name a3ong w:th dates and places where used. <br />S. Name and address of the liceused Massage Therapy Establishment that you �xpect to be employed by. <br />p `� C�.�,,.-.4�s ��� �,.�„-��'��u Ii��- � Zc>a�-�'� :�Sli_� <br />,4✓✓{° ��L-lt7tis�ci ��use✓�14 <br />9. Attach a certified copy of a diploma or certificaie of graduatiot� from a schoot af massage tlterapy <br />€ncluding a rninim�m of 600 haurs in successfully compieted course work as described ic� Rosaville <br />Drdinance 116, massage Therapy Estahlishments. �,t �' � 1� ��� �� 4� ���..� �,�[.� v�{4�1t�� <br />10. Have you had any pre�iaus massa�e therapist license that was revoked, suspended, or i�ot rene�+ed? <br />Yes _ No _� If yes explain in detail. <br />I,icense fee is 75.�0 <br />Make checks payable to City of Rosevitle <br />