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ma,ssag�e Therapist License <br />New License Vol Renewal <br />For License year ending June 30 6Vt eded I Jul <br />Legal Name res. a, 4 <br />2. Home Address <br />3. Home Telephone <br />4. Date ofBh* <br />5. Dfivers License Number <br />6. Email, Address <br />H <br />7. Have you, ever used or been ow� by any name other than the legal name given m* number I above? <br />Yes No If yes, list each name along with dates and pilaces where used. <br />if A a A <br />8. Name, and-address ofthe licensed, Massage Thprapy Establishment that yop expect tol be employed by, <br />9Ra1.9 <br />9. Attach a certified copy of a diploma or, certificaft of graduation from a school of massage therapy <br />.8 V * <br />includig a minimum of 600 hours m* successfiffly completed course work as described M" Roseville <br />al <br />Ordinance 116, massage Therapy, Establishments. <br />10. Have you had any prm*ous massage therapist license that was, revoked, suspended,, or not renewed'i <br />Yes No, Ifyes explain detail. <br />License fee is 100.00 <br />Make checks payable to City of Roseville <br />