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L I M a I <br />0 <br />New License Renewal <br />Fo�r L,i,c,e,nse year ending, June 30 <br />LAJ 14 ed 2, hex vt <br />1. Legal Name, elq - 1-'-9 <br />%IJ <br />2. Home Address , & <br />Home Telephont, f - <br />4. Date of Blirth . ?F <br />5. Drivers, License Number III % .- f <br />6. Email Address <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 If' es, list each, name, along, with dates and places where used. <br />11 V <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed9, <br />Yes, No If'y,es explain in detail. <br />License fee is 100.00 <br />Make checks, payable to Ciity of'R,oseville <br />