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ho <br />New License Renewal <br />FA <br />V F a J 30 <br />ror License -xrpar endm une <br />g <br />J <br />I., Legal Name, Ck rott H mar' <br />24 Home Address <br />eldoar, - <br />Email Addrei <br />7'. Have you ever used or been known, by any name other than the legal nee given in number I above? <br />Yes if es hsit each name along with dates and places where used. <br />8. Name and address of'th,e licensed Massage Therapy Establishment that you expect to be employed by, <br />r P. <br />o-P 14,CA4 Oodywork.. LL(, Oly PrOc4c <br />9. Attach a certified Ico py of a, diplomas air certificate of graduation from a school of massage therapy <br />ip <br />including a minimum of 600 hours in successfully, completed. course work as described in Roseville <br />Ordffiance 116 , massage Therapy Establishments. <br />10. Have you had any previous massage therapist li,cen,se that was revolked, suspended, or not renewed? <br />Yes No Vi If yes explain in det�ail. <br />gn6 — <br />License fee is 100.1010 <br />Make checks, payable to City, of'Rosev,ille <br />