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Massage Therapist License <br />Now License Renewal <br />For''Licensle year eniding June 30 <br />FAM <br />1. Legal Name elt, <br />,2. Home Aididriess, <br />3. 'Home Tielephione <br />4. Date of Birth <br />5., Drivers License Number <br />6. Email Address <br />7. Hav- iame other than the legal name givien in number I abovie? <br />es, list each name along with dates and, places where u1sield, <br />8., Name and, aididress of'the licensed Massage Therapy Establishment that you ex ect to he employed by. <br />P <br />5 Ti,1,A.1 oelt 16111- 7 C/ - 9 4� Ai T11 <br />47 5-T /? '40( <br />lziojrl iv/' It 4 <br />19. Attach a clert'ified copy of a diploma or certificate of graduation, from a school of massage therapy <br />inctudina a minimurn of 60 hours in successfully comp'leted clourse work as desicribed, Iin Roseville <br />C) <br />Ordinance 1161 massiagle Therapy Establ'ishments. <br />10. Havie v <br />y1ou had' any previous massage therapist license that was revoked, suspendeid, or not renewed? <br />Yes No ex, yes If lain in detail. <br />P <br />IF <br />License fee is'75.001 <br />Make chiecks, Payable to City of Roseville <br />