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���� � <br />� � <br />r <br />Finance Uepart�nent, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651)792-7034 <br />Massage Therapist License <br />h: �w License R�newat <br />For �,icensa year ending June 30 L� t't� r•r• <br />r� _ f ; <br />1 L.=��. ��i�it —I.-' ' ��i� _:.7� ��i �.. �_ �- �r� � ✓'- <br />2. Home Address. <br />3 Home Telephone u�r �. 4� - - ___ <br />4 Date of T�ii [}� <br />5. ��ivers License Number <br />6. ETiiail Address <br />��sve you ever �s�d or been know�i by atiy �,a�e other than the legal name given in number 1 above? <br />Yes No If yes, list each naine a1�n� �uitl� dates and places wl�era �a� <br />8. Nani� tii; � address of thelic���� iYlassage Therapy Establislirr,e;�t that you eXpect to be. employed by. <br />�•�� C r•+1-- � •3 • � rl. f %l . ' �� � $ ' .�.�. �f �� ��'_ �� � <br />1-7 r�1a �� �L �.• 7-- : _� n � . . . <br />.�_ � . <br />�. �ttach a ceiiified copy of a�iylosna of certificate of graduation from a school of massage iherapy <br />including a minimum of 600 hours in successf�lly completed t�•.I���� ��;k as described in Roseville <br />� <br />Ordinance ll 6, massage Therapy Establishments. r l r�_�,� .��, ��. ;i <br />i r <br />�0. ii�ave you had any previous massage t�arapisE license that was revolced, suspended, or �o� renewed? <br />Yes No �� If yes eXplain in detail. <br />License fee is 75.00 <br />Malce checics payable to City of Foseviffe <br />