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Attachment A <br />M <br />New License <br />Massage Therapist License <br />Renewal <br />F'orLice�nse year e�n, din gJune�30 1*1P'Wt-ejjj' <br />L, Legal Name <br />Home Address <br />3. Home Telephone <br />4. Date of Birth <br />5. Dri'vers License NumbIer- <br />61. Email Addre�ss,— <br />71. Have you ever used or beep known by ern.. ° name other than the legal name given in number I above9 <br />Yes, No If yes, list each name along, with dates and places where used." <br />9. Attach a certified copy of a, diploma or certificate of graduation from a school of massage therapy <br />including a, minimum of 600 holUrs, 'in successfulfly completed course work as described in, Roseville <br />Ordinance massage Therapy Estabilisihments. <br />I 1 0. Havie you had any previous massage therapist license that was revoked, suspended, or' not renewed? <br />Yes, I No )4 - If yes explain in detail., <br />License fee is 100.001 <br />Make checks playabil,e to City of Roseville <br />04 - <br />