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' ��� ' � ����� <br />� <br />Finance Departmeni, License Division <br />2660 Civie Center Drive, Rnsevill�, MN 55113 <br />(b51) 792-7034 <br />Massage Therapis� License <br />New License RenewaI i/ <br />For Lic�nse year ending June 30 �, n�.��i.' ,,,,-, W,. �� <br />1. Legal Name �� � � G� i�' �� t L- '�' f <br />2. Home Addres: <br />. �..-------....r— <br />-- r _.rr <br />3. Horne 'I'elephone_ <br />4. Date of Birth <br />,� , ., ,� �- - <br />S. Drivers License Nurnber <br />0 <br />6. Email Address <br />7. Have you ever used or been k.nown by any name other than the legal name gi�en iit number 1 above? <br />Yes __ No _ If yes, list each name along witf� dates and places where �sed. <br />' � - • . _ .. , �`t r �, =� <br />8. Name apd address nf the ticenseci Massage Therapy Establishment that you expect to be enipto ed by. <br />t' '� .i % ' ° C� �'�V ��u� r' P r , �l� r � �'G �l � � � � lO� <br />9. Attach a certified copy of a diptama or cerEificate of gradtta#ion from a school of massage tIaerapy <br />including a minimum oi�600 hours in successfuliy comple#ed cvurse wark as described in RaseviEle <br />Ordinance 116, massage T13erapq EstabIishments, ��,0 j����� <br />I0, Have you had any previaus massage therapist iicense tf�at was revaked, suspended, or r�at renewed? <br />Yes. No ,.� . , If yes explain in de#ail, <br />License fee is 75.00 <br />Make checks payable ta City of Rosevili� <br />