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New License Renewal WVMRO� <br />For License year end 'Ing June 310, 20111 -- — <br />1. LegaiNme.-L1451a <br />It <br />2,. Hoine Address %Or <br />3. Home Telephone g 11hol - "ll wkwr, M ®1 <br />A#W <br />mw � 6&" A"W F Al SMawr 11 <br />51% Drivers License Number <br />6. E mail Address P, 1111 ., ftD 4MV, %viv - 1P - - _ %;OP %.l P ■ 16 !tffd %;,I I . 01 1 %ft.W 4 <br />71. Havie You everl used or been known by any name other, than the legal, name, given in number I above? <br />Yes WOOOP"i NO If yes, list each narne along with dates and places where used. <br />I lap ne that, yoi <br />S. Name and address -oftlile lii�ce,ns�eld Mass crap Establishment j expect to be employed by. <br />Ap <br />Lot Tt*rne Fill"n4o. P4180 F60 Ic"O ArJe- <br />9. Attach a, certified clo,py of a diploma, or cerfificate of graduation from a sc,h,00l of massage therapy <br />incl lu,ding a rniimum of' 6110 0 bourn in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establi'sliments., <br />10. Havle, you had any previous massage thempist hicanse that was, revoked, suspended, or not renewed.? <br />Yes No &000 If yes explain *M de ii. W) <br />License fee i's <br />Make checks payable to, City of'Roseville, <br />