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fa <br />MassageTherapist License <br />New LicenSe <br />For License year, ending June 30 <br />I Legal N,ame <br />2. IHome Address <br />I Home Telephone <br />4. Date olf'Birth_ <br />5, Drivers License Number <br />6, r-u-nall Addrcss <br />V <br />7. Have you ever used or bleen, known by any name other, than tlie legal name given in number I above? <br />yes No If yes, list each nme along with dates and pies where used, <br />8,. Name and address of the licensed' Massage Therapy, Establishment that you expect to be employed by. <br />SO-1-10k.2 zS�- �L 16WIAZ-2-A4 Pka2' 1�! <br />9, Attach a certified copy of a, diploma or certificate of graduation from a, school of massage therapy <br />11 <br />including a minimum, of 600 hours 'in successfully completed course work as describled in Roseville <br />Ord *Inance 116, as,sage Therapy Establishments. <br />0. Have you had any previous massage therapist ficense that was revoked,, suspended, or not renewed7 <br />Yes I If'yes, cxpilain 'in detai,l, <br />L'Icense fee is 1001, 00 <br />Make checks payable to City ofRosevillie <br />