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LI <br />New Liic�e,ns�e, Renewal <br />;AOfi r <br />Fair License year, enicl 'Ing June 30 " p- <br />lfm� <br />1. Ise gal'Name _dA14At. <br />Am <br />2. Home Address S.= WA&% k k WI1110 <br />Home 'Telephone <br />4. Date, of Birth. <br />5. Dr1i'vers License Nu,mbe <br />6, Email Address <br />7. Have you ever used or been tuiown, by any name other than the legal name 91 iven in number I above? <br />Yes No If' yes,,, list each name along, with dates and places where used. <br />:.1 <br />01 <br />9. Attach a certified, coply of a id i1plorna. or certificate of'grad uation from, a school of massage therapy <br />lncludjju, a minimum of 600 hours in successfully completed course work, as described in Roseville <br />Ordinance I 16, inassage Therapy Establishnients* <br />10. Have you had any previous massage therapist license. that, was revoked,, suspended, or not renewed? <br />00-11, <br />Yes No If' yes explain in detail. <br />oe- <br />License fee 14 t4b, "I Ob <br />Make checks payable to City of Rosevidle <br />