Laserfiche WebLink
��� .: �� <br />�' � . .� . <br />�`ina�ce �}epartme�t, License Davision <br />2660 Civic C'enter �rive, Rasevil�e, N�N 551 Y3 <br />(65I ) 792-7036 <br />l�a�sa�e Therapis� License <br />New I_icense _�� �� Renewal <br />FoE• License year endin� lune 30 <br />1. Lega€ Na���e �' i I � � � _. _�— �.� _ .�— <br />• � � . _ _ -� .- . _ � <br />2. Home Address <br />� � _ � .� __ � � ' - �` - <br />3. Home 7`elepl�o�le <br />�. Date of Bi�-th _ . _ _ <br />�. Drivers License Nuir�ber �, <br />6. Emai� Address <br />7. Have �ou ever used or been }- � � a��y narne other than the legal �aarne gi�en in nunlber I above? <br />3f yes, list each name along with dates and places w}�ere used. <br />8. Nzme and dress of the licensed Massage TE�erapy Es�biis�rnent that you expec€ €o be..empl <br />) r, n Il r� n, k � � .4� ,. 1 I ..r, .. .-. i .. _ ,� .. <br />'��e� f 4I�� m � � � t <br />9. Attach a ce�Kifed copy of a cfiploma or cer�ificate of graduation fi•om a school of massa�e therapy <br />including a a�ini�num of 604 ltnurs in s�ceessfuE€y completed course work as described i» f�oseville <br />Ordinance 1 16, inassage Therapy Establishments. <br />10. }-lave you f�ad any �Srevinus �nassage therapist iicense that «�as revoked. suspended, or �3nt rene����d? <br />Yes ____ No � [f yes eaplain in deta€I. <br />I,icense fee is 75.00 <br />Make checks payable to City of Raseville <br />