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0 1P, <br />Massage Therapist License <br />New License Renewal <br />For License year ending Juine <br />/21 <br />1. Le2al Name mitr I/ e Z - )0 �-f -) 6 <br />2. Home Address #1 4r <br />3. Home Telephone <br />4. Date ofBirth <br />5.1 Drivers License Number i <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 If Yes, list each name along with dates and places, where used <br />6 <br />10., Have you had any previous, mas�siage therapist license that was revoked, suspended,, or not renewed <br />Yes No I if yes explain in detail. <br />License fee is, 100.00 <br />Make checks payable to City of'Rosevillel <br />