Laserfiche WebLink
Massage Therapist License <br />New License Renewal <br />For License ear ending June 30 <br />1. Legal Name rL <br />A <br />2, Home Address <br />3. Home Tel, <br />4. Date of Birth <br />5. Drivers, License Nui-nIber----.,. <br />6. Email Address, <br />0, <br />7'. Have you, ever, used or, been known, by any name other than the legal name given in number I above <br />Yes No I <br />if yes,, list each name along with dates and places where used <br />C= , yo,, e e t to )e ployed by- <br />8. Name and a, dress o -e i,cen,s,eid Massage Therapy Establi ih,ment that" you e e t, to be em <br />IPI 1 <br />9. Attach, a certified copy of I d loma or certificate of graduabon from, a school of' massage therapy <br />including a minimum, of 6'00 hours 'in, successfully, completed. course wiork as described in Roseville <br />I <br />Ordinance 116,1 massage Therapy Establi'shmeints., <br />10. Have you had, any pire�vi�ou age therapist', license that was revoked,, suspended, or not renewed <br />Yes, No Y� If yes, explain in detail. I <br />License, fee is 100-00I <br />Make checks Payable to, City, of Roseville <br />