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F i a n c e Department, License Division <br />2660 Civic Center Drive, Roseville, �T 55113 <br />(651) 792-7034 <br />Massage Therapist License <br />New License � Renewal � <br />For License year ending June 30 ��t� <br />� <br />� . Legal Name � ��, �� - � <br />- - �� _ � <br />2. Home Address � ,� t_ _ <br />3. Home '�e�aphone � <br />4. Date of�artl� <br />�: <br />5. Drivers �X�et�se Nurnbsz _ <br />�s .n .. . , mm .�-� — <br />6. �:ncta.i� Address, <br />�+ <br />7. Have you ever used or been �t v�z by any name other �atz the legal uax�ze given in number J. above? <br />Yes No � If yes, list each name alo�g with dates and places where used. <br />g�.Ta a,a ��a�r�s, f r1,P 1;r,Pnsed Massa � Tbrra��r �siab=.i�}�trni that you ex�sect ia be er� rpc�d tr�. <br />_������ �� �L$�� .��������� � � �� ���� <br />9. ,A.itac� a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a z�r,��iz�.ixrauzn of 60�T hours n successfully completed course worlc as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />�� �� �-.�' -..-,..._-_. I� yes explain in detail. <br />License fee i s 75.00 <br />Ma1ce ehec� payable to City of Roseville <br />