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New License Renewal <br />For License y1ear endin�cy June 30 00 9 <br />I. Lielcral''Narne <br />L <br />Home Adidriess—, <br />3. Homiel'Telephorie <br />Date of Birth <br />5. Drivers Lilciense Nurnbe <br />6. Email Address <br />T, ',have you evierl uil;ed nr name othier than the legal nacne given in numbler I abilovell?. <br />yies JL 11 <br />yes, I ist each name ai ong vvith, dates and Places where use d. <br />�81 = al addriess of the licensed Massage Therapy Establishment that you Iexpect to bile emplioyed by. <br />9. Attach a clertifiled copy of a diploma or certificate of graduation from a school Iofni assagiethiera� y <br />i,niclludincy a mini , mum loif 600 hours in successfully completed course iwoirk as diescribield in Rosievill' <br />g le <br />Ordinancie 11161, massage 'Therapy Establishments. <br />zz <br />10. Have y ou had slay p rev i ou s masses th era p i st I i cc n s le, that was re vok e- id , s u s pie n id ield, ol r root Ire n ewed? <br />Yes No I- - -- - lf yes explain in dietail. <br />Licensic fee i's 75.00 <br />Make checks, payabile to City of Roseville <br />