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�i�� ��` <br />•r„�+�+` � ���� <br />Finance Depar�ment, License Division <br />2660 Civic Cen�er D�-ive, Rosev�lle, MN 55113 <br />(651) 792-7034 <br />Massage Therapis� License <br />New License RenewaI r�" <br />Far License ear endin June 30 �-�..1��i`� r�- �r � <br />Y g � ..:.,.. . <br />I. Legal Name �v �. ,'� � � �f� �'t!i �li'�`�ll� <br />2. Home Address <br />3. Home'I'elepllone_,�, � <br />4, Date of Birth <br />�, <br />5. Drivers License Number � - <br />(. Email Address ��„_� <br />7. Have you ever used or beecl knovcm by any name other than the lega! name givei� in number 1 above? <br />Yes _ _ No �, If yes, list eaeh name atong with dates and places where used. <br />8. ,�a�ne and address pf the licensed Massa e Therap� Establishmer►t t at you e ect t be emp oyed b , <br />��-� �,- r ���,� , �f�s ��c� � � r �� ,� � "� � j , ���i�i <br />t: ,j� ,(.� ,���� � ,j <br />9. Attaeh a cerfified eopy of a diploma or certi�caCe of graduation from a school of massage therapy <br />including a tninirrium oi 600 hours in sueeessfully cotnpleted cours� work as described in Rosevitle <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was re�oked, suspended, or nat renewed? <br />Yes` � No ��„ If yes explairi in detail. <br />License fee is 75.Qa � <br />Make cl�ecks payable to Ciry of RoseviIle <br />