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Attachment A <br />z RTV P-I "I I ROF M <br />....... ....... <br />A <br />71-assage Therapist iLicense <br />Renewal - X <br />For License year endingl June 30 ft�24 1 <br />Ift <br />1. Legal Narne- fA i C, N JJ rIM 4 IrT <br />I Home Address <br />3. Home Telephon( <br />4. Date of Birth vjle w <br />5. Drivers License Number. <br />6. Email Address **q� <br />Have you ever used or been known by any name other than the legal name, gi*'ven "in number I above <br />Yes NO r If yes, list eiach name a with dates and places where use <br />long di <br />8 1 <br />Name and address of the licensed Massage Therapy, Establishment that you expect to be employed by. <br />0& t TV01 *bq Ao&*b 45;0 rL L Ad 8;-S-4q, 0 L AJ TZ7]p,,, <br />2.-z.ol L'&Y-eneP7vAJ A-\J0*4IWs s^orr,403P 015e-v t L'CLI' <br />9. Attach a certified copy of a diploma or certificate of graduation, from a school] of massage therapy <br />0, <br />mcluding a mffiftnum of X00 hours "in successfully complete'd course or as described in Roseville <br />I <br />Ordinance 11,16', massage Therapy Establishments. om <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes, No If yes explain in detail. <br />License fee is 100.00 <br />Make checks, payable to City of Roseville <br />