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New License <br />Massage Therapist License <br />Renewal, A' <br />For License year ending June 30 12 11 <br />mp- - <br />I Legal Nye <br />2. Ho+ m e Address <br />3. Horne Telephone <br />4,. Date of Birth <br />5. Drivers License Number <br />0' Q <br />6., Emai,l, Address <br />7. Have you ever used or been known by any name other than the legal n ame given in number I above? <br />Yes No )4 if yes list, each name along with dates and places where used. <br />Name and, address of the I icensed. Massage Therapy Establishment that you expect to be employed by. <br />41DII", (711,46�L r-t. it,, 2"� -v OA&I), , F.Os4u, 16 itj ItJ rs <br />9., Attach a certified copy of a diploma, or certificate of graduation from a school of massage therapy <br />9 01 41 <br />inicluding a minimum of 600 hours, in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had and previous massage therapist license that', was revoked,, suspended,, or not renewed? <br />Yes, No, X - If yes explain in detail. <br />License fee is 100.010 <br />Make checks payable to City, of"Roseville <br />