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Attachment A <br />a License Massage Therapist <br />. . . . . .. . . . ...................... <br />New License Renewal <br />For License year ending June 301 <br />I Home Address j ' <br />3. Home Telephone <br />4. Date ofBirth <br />5. Drivers License Number - <br />16. Emifflfl Address <br />7. Have you ever used or, been <br />No by, any name other than the legal name given in number I above? <br />Yes Wyes, list each name along with dates and places where used. <br />I III lie <br />k Amon qqMW A <br />9. Attach a, cerfified copy of a diploma, or cerfificate of graduation from a, school of massage therapy <br />MI <br />tacluding, a mm"u"num of 16010 hiours m" successfully completed course work as described M' Roseville <br />Ordinance 116, manage Thempy Establishments. <br />V <br />10. Have you had any previous massage therapist license 69 was revoked, suspended, or not renewed? <br />YesI yes explain M' deWl. <br />License fee is 1 100. 001 <br />Make checks Payable to City of Roseville <br />