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4. Date of B,irth_ <br />Drivers License Number_,,. <br />6. Email Address <br />7. Have you ever used or been known by any name other than the legal name given in number I above? <br />% I <br />Yes A NO If yes, list each name along with dates and places where used. <br />Jr <br />10. Have you, had any previous sia,ge therapist licens,e that was rievoked, suspended, or not renewed .7 <br />i <br />Yes No If yesi explw*,n in detail. <br />License fee i's 100.00 <br />Make checks payable to City of Rosevil"IT" <br />