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#-�� <br />��4� , <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651)792-7034 <br />Massage Therapist License <br />_ New License �� Renewal <br />.{ �� <br />_ For License year ending J�a�e 30 <br />I i_L'�8I �Al1YL' <br />� f-� . � _� �� ��.�_��.._ ?��� <br />2. Home Address- <br />3. Home Telephone � <br />4. Date of Birtl� <br />5. Drivers License �lwnber <br />6. Emai! Address <br />'7, Have you ever used ot• been lcnown by any name other than the legal name given �t� number 1 above? <br />Yes _ _ No ' If yes, list each �na�ne along with dates and places where used <br />8. Name and address of the licensed Massage Tl�erapy Establishment that ou expect to be employed by. <br />�^� �� w�#' �;.. =�.�?�1-3 _�=�_���� �?'-r—�*� �—{r�''� ��-�� 5} ��1 �4 L` 5 �}k S � <br />9. Attach a certified copy of a diploina or certificate of graduation frain a school of �nassage therapy <br />including a minimum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revolced, suspended, or not renewed7 <br />�-cs_ _— �¢ — _ . If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />