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ail & <br />3. Home Telephone iWWW4 0 - 01 <br />t 1 <br />4. Date of Birth <br />Drivers License Number- <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 t4�, If yes., list each niame along with dates and places where used <br />V I <br />8. Name and address, of'the beensed. Massage Therapy Establishment that you expect to be employed by. <br />gasd' <br />9. Attach a certified copy of a diploma or certificate of,graduation from a school of massage therapy <br />T 9 <br />including a minimurn of 600 hours in successfully complieted course work, as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previ"ous massage therapist license that was revoked, suspended, or not renewed.) <br />Yes No . If yes explain, in detail. <br />License feeis I O01-00 I <br />Make checks payable to City of'Rosieville <br />