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New License <br />For License year ending June 30 <br />If M, <br />2. Home Address 4 <br />3. Home Telephone <br />4. Date of Birth <br />I I a a <br />MU= <br />Renewal X, <br />le Jt <br />/ f <br />Dri'vers License Number W.O* <br />6., Email Address <br />7. Have you ever used or been known by any name other than the llegal name given in number I above .9 <br />Yes ' I X — If, yes, list, each name along with dates and places where used. <br />8. Name and address oft e licensed Massage Therapy, Establishment that you expect to be employed by. <br />TlelAliek AIA- 70-44 el�P W-�W J100011, lelet 5r <br />9. Attach a certified ic,oply of a diploma or certificate ofgraduation from a school of massage therapy <br />including a mini�mum, of 16001 hoursin successfully completed course work as, described 'in Roseville <br />Ord mance 116, massage 'Therapy Establishments. <br />10. avie you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Y'ies No If'yes explain in detail. <br />License fee is 100-00 <br />Make checks payable to City of Roseville <br />