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2011_1114_packet
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2011_1114_packet
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1/10/2012 9:44:23 AM
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11/15/2011 12:01:25 PM
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Massage Therapist License <br />............ <br />New License Renewal <br />For License year, ending-fmw-N Z 4;21 0/1 4z <br />(;*1 <br />2. Home Address A I L.Z -. q L-L I <br />f <br />3. -Korne Telephone <br />4. Date iof'Bi,rth <br />5 . Drivers, License Number <br />6. Email Address <br />.................................... .. <br />8'�. Name and address of the licensed Massage Therapy Establishment that you ex <br />R P 10-16ole-'r C-hr)-ic A� )Jnmbiriv AA�f, <4P--ff :z4ol <br />o- employed by. <br />9. Attach a, certified copy of a diploma, or certificate of'graduation, from, a school of massage therapy <br />includm*g a minimum of 6100 hour's 'in successfully completed course work as described in Roseville <br />Ordinance 116, massage Tberapy Establishments. <br />1. 0. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No- X - If yes, explain in detail. <br />License fee is 1001.0�O <br />Make checks payable to City of Roseville <br />
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