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3 a I m a f a <br />w3 1 <br />New License Renewal <br />For License year ending June 30 ............... <br />1. Legal Name /), <br />Ic ck (e- 41 ( j � <br />2. Home Address <br />I a -- IV <br />3. Home Telephone <br />W <br />. . . . ......................... ujijjjjjj9�pj <br />4. Date ofBirtf <br />5. Drivers License Number <br />Email Address <br />a <br />7. Have you ever used or been n by any name other, than the le� ame g'al n given in number I above? <br />Yes N'ol r — If yes, I ist, each name along with dates and places were used. <br />8., Name and address of'the licensed Massage Therapy Est blishment that you expect to be employed <br />by. -0 "1 16 7 (Ova f I? d. C <br />15erene, 13a,Ay 7ht^PlV- 43li*,'jjr,, (L4,M', 5-illr'11.3 <br />IF <br />19. Attach a certified copy of la, di"plorna or certificate of,graduation, from a school of massage therapy <br />0, % P <br />including a minimum, off" 00 houris, in successfully completed course, work as, described in Roseville <br />I <br />,Ordinance 116'.. m,as�slage Therapy Estabilishments. <br />10. Have you had any p liolus, milassage therapist I ic,en�se that was revoked,, suspended, or not renewed? <br />0 <br />PC <br />