Laserfiche WebLink
Massage Therapist, License <br />2, Home Address--,,,-,/, <br />3. Home Telephone <br />-C Date of Birth <br />5. Drivers License Number <br />6. Email Address <br />7. Have you, ever used or been k own by any name other than the legal narne givn in number I above? <br />- ^ yes, list each name along with dates and places where used, <br />V. Name and address of the licensed Massage Therap <br />,,y Establishment that you expect to be employed by. <br />Po <br />9. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including , minimum of 600 hours in successfully completed course work as described M' Roseville <br />01 1 <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No Y::: If yes explain in &tail. <br />License fee is 75.00 <br />Make checks payable to City, of Roseville <br />