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Massage Therapist Lincense <br />New License X Renewal <br />For License year lending Junie 3 01 <br />1. Legal, Name, LOV <br />\ V% t>-TA A) A <br />7. Have you ever used or been known by any name other than the legal name en <br />giv in number I above? <br />Yes, No X — if yes, list each name along with dates and places where used. <br />Name and address, of'the 1"censed, Massa e Therapy Establishment that you expect to be employed by. <br />9. Attach a certified, copy, of'a, diplonia or c,erti,ficate of graduafion from a school of massage therapy <br />including a mininum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previlous massage therapist license that', was revoked, suspended, or not renewed? <br />yes No, X – If yes explain M* detail. <br />da <br />Lic ens e'fee is 100.06k�, <br />'Make checks payable to, it of'Roseville <br />1. <br />