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10 <br />Massage Therapist License <br />. ...... . .. .. .. ... . . . ...... ............... — <br />I UNINININIMP-MONIP" <br />New Licens�e, , Re�newal, Lo� <br />For L,imuse year ends rig June 30 aotl <br />1. LegalNwne. bww Q(%(%!bOSifn <br />2�. Home Address IR dr <br />3. Home Telephone, ........ . .......... .. .. .. <br />4. Date of'Biirth- <br />9 <br />5. Drivers License, Number -Smor - <br />6. Email Address %.4VVW% <br />7. eve you ever usiod, or been known, by any name other than the legal name given in number I above? <br />to . <br />yes No Le< if yes, ast each name along with dates and places where used. <br />License &e, is "AG. <br />Make checks, payable to City of'Roseville <br />