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Massage Therapist License <br />New, Licens e Renewal <br />For License year, ending June 30 <br />1. Legal Name (]O�MV' In I <br />2. Home Address —.Pop It <br />d1f!hN!t-d1C <br />3. Home Telephone <br />C Date offfi"Tth I <br />5. Drivers License Numbe. j <br />61, Email Address -\4J <br />71. I e you, ever used or been k I e . <br />\7wn by, any name other than the legal name given in number I abov' 9 <br />Yes No 1f' es list, each name along with dates, and places where used <br />11 lo <br />6jmmb; <br />/A <br />9, Attach a certified copy of a dl'ploma or certificate of graduation from a school of massage therapy <br />41 # Q <br />I , n,cluding a minimum of' 6100 hours in successfully completed course work as described in Roseville <br />Ordinance 1161, massage Therapy Establishments. <br />10. Have you, had any previiolu sage therapist filicense that was tevolked, suspended, or not renewed'i <br />S 111L <br />Yes No V If yes explain in detail. <br />L ol <br />icense fee is, 1100.00 <br />Make, chiecks payab�le to City of Roseville <br />Please fil I out and send to the Rosevile <br />Finance Lic. Dept with your fee by June 24th. <br />Ii17711 ITI IN 1111V <br />0, <br />