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New License Renewal <br />For License year, ending June 3 0 <br />1. Legal Nwne <br />� �-k <br />a <br />I ink XW, 1h.- <br />I Home Address, <br />A"P hL _4plfti V <br />31 Home Telephone! now a 4CW <br />4,. Date of Birth - IMP- %_.O ___'O 1 11 __j <br />5. Drivers License Number <br />6., Emal'I Address 2L <br />7. Havie you ever used or bee rl kn9wn by any, n other than the legal name given M* number I above? <br />Yes No If yes, list each name along with dates and places where used. <br />10. Have you had any previlous m 1 sage therapist ficense that was revoked,, suspended, or not renewed? <br />Yes No ';t7 Uyes explain in detai'l., <br />License fee is 1, 00.00 <br />Make checks payable to City of Roseville <br />