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A w 10, <br />Massage Therapist jbicense <br />New License Renewal <br />For License year ending Junle 30 <br />fit <br />1. Le Name 00 j .3 <br />A,4 <br />gal - C'e, . i ( I <br />�7 <br />2. Home Address .�-- �.. ,� . r <br />. .................. <br />3. Home Telephone <br />4,. Date offfirth <br />5. Drivers License Number <br />6. Email Address . - ­ — -1 lu=. % � <br />7'. Have you ever used or been known by any name other than the legal nwne given in number I above? <br />Yes No, If yes, list each name along with dates and places where used,. <br />9., Attach a certified copy of a diploma, or ceftifficate of graduation from a school of' maissage therapy <br />P V P <br />ncluding a minimum olf'6001 hours in successfully completed course work as described in R,olsieville <br />Ordinance 1, 16'1, ma,ssag r <br />blishment& <br />10., Have you had any previous massage therapist license that was revoked, suspended, or n�olt renewed' t <br />Yes No X' if yes, explain in detafl. <br />L license fe�e IS, 1001. 00 <br />Make checks playable to, City of R,olseville <br />