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�,.,/�h�� �� wl ~' ww1� �� <br />7r <br />Finance Depariment, License Division <br />2660 Civic Center Drive, Rosevill�, MN SS�i3 <br />(651} 792-7p34 <br />Massage Therap�st License <br />New License Aenewal �,� <br />For T.icense year ending June 30 ��. __ T... •,_{_ <br />l. Legal Name �._,,�(s�Ylt�`�� fL�"���C���`�.C� ��� <br />2. Home Address � <br />3. Home Telephone <br />4. Date of Birth <br />5. Drivers License Nuinber <br />&. Email Address �~�� <br />� <br />7. Have you ev�r used or been i�r►own by any narne other than the legal nama given in nurnber 1 above? <br />Yes No "�� Ff yes, list each name along witi� dat�s and places where used. <br />8, Name and address of the licensed Massage Therapy Estabiishment that you expect to be ernployed by. <br />-�'�.- �C ' ^,-��r " C� �GL�'r-�t j�' ,(�t� <�,r-�_ � �i � l I`Y4 <br />9. Attac� a certified copy of a diploma or certificate of graduation fram a school of massage therapy <br />including a�minimum of 50� hours in successiully co�npieted course work as described in Roseville <br />Ordinance 116, massage 7'herapy fistablishments, <br />I0. Have �nu had any previous massage therapist license ti�at was revoked, suspendect, or not renewed? <br />Yes No � _ If yes explain in detai�. <br />Lieense %e is 75,00 - <br />Make chac�CS payabte to City of Rosevilte <br />