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Massage Therapist License <br />. .. . .... . . .................................................................................................................................................................................. . ..................................................................................................................................................................................................................................................................................................................................................................................................... <br />New Lic,ensiie Renewal <br />For License year, ending June 30, <br />1. Legal Name <br />&4% <br />Home Address <br />3. Home Telephone w,,, , — ,,, Lv <br />44, Date ofBirth <br />5. Drivers License Number <br />..... ...... . . . <br />6., Ema1*1 Address <br />A;zl <br />7. Have you ever used or been known by any name other than the legal, nwne given in number I above? <br />Yes, V No If yes, list each name along with dates and places where used. <br />A, <br />=I AWV <br />9. Attach a certified copy of'a diploma or certificate of graduation, from a school of massage therapy <br />4 <br />including a minimum of 6100 hours in successfully completed course work as described in Roseville <br />Ordinance H 6, massage Tberapy, Establishments. <br />10. Have you had any previous massage flierapist licensle that', was revoked, suspended, or not renewed <br />Yes No, 1z If yes explain, in detail. i <br />License fee "is 100.00 <br />Make checks pa able to City of Roseville <br />