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�� � <br />,�,� �. <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 />For License year ending June 30 ��,� <br />�_ � <br />� { <br />I . Legal Na�-nem� � I t��` �.�� �l �'� ���� � � = <br />�; . <br />n. �i�y17C' r�;�r� �� . r �.t� , . •" <br />�. Home Telephone <br />�4. Date of Birth. <br />r■ � <br />_ . Drivers License Number- �. <br />G. �xnail Address <br />m <br />U <br />�, <br />. Have you ever used or been known by any name other than the legal name given in number l above? <br />Yes No �_ If yes, list each name along with dates and places where used <br />8. Name and address of t P 1;�P„�P�l Massage Therapy Establishment that vou exnect to be employed by. <br />���`(: _, d�1�L�a� �'���� F�• �'�`i��+d��f'r ���'�` � �i�-� <br />9. Attach a certified copy of a diploma or certificate of g�•aduation from a school of massage therapy <br />including a rr�iniinuf�, of 600 hours in successfully completed course work as described m Roseville <br />Ordinance L 16, massage Therapy Establishments. <br />� 0. Have you had any previous massage th�rapist license that was revoked, suspended, or not renewed? <br />Yes '��' _�� . ifyes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />