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� <br />�.�� <br />Finance Department, License Division <br />26b0 Civic Center Drive, Roseville, MN 55113 <br />(651) 792-7036 <br />1V�assage 'Therapist License <br />New License � ` Renewal <br />For License year ending June 30 <br />I. Legal Name � � , � • <br />2. Home Address� <br />J <br />3. Home '£eiephone <br />4. Date of BirEh <br />5. �rivers License Number <br />6. �mail Address <br />Attachment A <br />7. Have you ever used or been known by any name other than the legai name given in number 1 above? <br />Yes No �.._ If yes, list each narr�e along with dates and places where used. <br />$. Name and address of the ]icensed Massage Therapy Establishment that you expect to be emp]oyed by. <br />—��� _N, l�e.,r�1 ��,�' l�.1J�; �:oSEU� 11�,_�n. 5511� .. <br />�v �ta i 1p <br />`�`r i'1 (� V� yr L� l Yl � 4 .... <br />9. Attach a certifled copy of a diploma or cer[ificate of gradua.tion from a school of massage therapy <br />including a minimum of 6�0 hours rn successfully campleted course work as described in Roseville <br />Ordinance 1] 6, massage Therapy Establishments. <br />1Q Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No 1� If yes explain in deTail. <br />License fee is 75.00 <br />Make checks payable to City of RosevilIe <br />