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New, License Renewal <br />- - <br />Address Ar <br />31.1 Rome Telephone <br />4. Date of Birth <br />Drivers License Number - I - - %&- W <br />6., Email Address, <br />T Have you ever used or been, knoiwn by any name ether than the legal name given in number I above? <br />Yes o If yes, list each namie along with dates and places where used. <br />8. Name and address of the licensed Massag,e Therapy Establishment that you expect to be employed by. <br />I I - I <br />7RZ—A-- V-P dw <br />W"i I low L-LC <br />9 1, 1, 1 rom a school of massage therapy <br />Attach a, certified copy ofa diplorna, or, cert"ficate ofgraduat"on f <br />inic,luding a minimum, of 6iOO hours in, successfully complieted, course work as described in Roseville <br />Ordinance 11, 6, massage Therapy, Establishments., <br />10. Have you had any previous mass I e them pis�t license that was revoked, suspended, or not renewed? <br />Yes No If'' yes explain in detail. <br />License fee is 100-100 <br />Make checks payable, to City of' Roseville <br />