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MASS- <br />New License Renewal <br />4. Date of Birth <br />5. Drivers License Numbc <br />6. Email Address <br />7. Have you ever used or been k�iqwn by any name other than the legal name given in number I above? <br />Yes — No — If yes, list each name along with dates and places Where used. <br />8 1 <br />N4me id address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />S -7qto <br />9. Attach a clertifiled, copy of a diptorna or certificate of graduation from a school of massage theral)y <br />including a minirnum of 600 hours in successfully completed course work as described in Roseville <br />,Ordinance 1116, massage Therapy Establishments. <br />10. Have you had ati�v nreviolle therapist licensc that was revoked, suspended, or not renewed? <br />Yc 1% If yes, explain in detail. <br />License. fee is 75.001 <br />TvIake chiecks payable to City, of Roseville <br />