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�4i9 <br />Finance �epartment, License I3ivision <br />2bf�4 Civic Cen#er I3�-ive, Roseville, IVIN 55113 <br />(651 j 792-7Q36 <br />�Iassage 'Thera�ist I1�cense <br />New Licer�se � Renewal <br />For License year ending .i�ne 30 �C� �� <br />� . Legal � <br />Name �S�(�i�4,� � _ �c�`l'�SC� 1 <br />2. Horne n -,��,` {�� �� � 1 � <br />Address � � 3 [�S�f1iCi� 1� '� �l �_�_ ��" ���1,_,� ��4 V c.7� l�1 "1 <br />3. Home _ <br />Telep�ane � <br />4. Date of Birth <br />5. Drivers License Nu�nber <br />6. Email Address <br />� � <br />n <br />7. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes No � lf yes, ]�st each name along with dates and places where used. <br />$. Na�e at�d address of the licensed Massage Therapy Establishment that you expect to be employed <br />�y� �����-; �1 ���� �.. .,. 5����_�.°��S ����e v�11 � ('�1� �S 11 � <br />9. Aitach a cectifed copy of a diplorna or certificate of graduation frorrt a school of massage therapy <br />includin� a minimurr� of 600 hours in successfully ccsrnpleted course worlc as described in Roseville <br />Ordinance l] b, massage Therapy Estabiishments. <br />