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�� <br />���� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, NI� 55113 <br />(651)792-7034 <br />Massage Therapist License <br />New License � Renewal <br />For License year ending June 30 ��_�� �. <br />1. Legal Name��,}��-�j ,�,'� _ ��,��� <br />2. Home Address � � � � �� �� �� <br />3. Home Talephon� <br />4. Date of Birth <br />5. Drivers License Number <br />6. �maii Address <br />7. Have you ever used or �i k re � Lr;� any name other than the legal name given in number 1 above? <br />Yes No If yes, list each name along with dates and places where used. <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to he employed by. <br />� ��' �� ��+i � �d � r.',r3�f_� <br />9_ Attach a certified copy of a diploma or c�rtifiicate of graduation from a school of massage therapy <br />including a minimum of df}D hours in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Ha�e you had any previous �7a- •� therapist license that was revoked, suspended, or not renewed? <br />Yes No If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />