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Massage Therapist License <br />--------------------------------- - - <br />New License Renewal X <br />For License year, endm"Ig June 30 2,0 12, <br />4. Date of Birth <br />5. Dri'viers License Number <br />61. Emalfl, Address IAZ F ip t <br />0 <br />10. Have you had, any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No I�f'yes explain M" detEdl. <br />License feie is 100�-00 <br />Make checks, payable to City of Rosevilty <br />