Laserfiche WebLink
Massage Therapist License <br />New License /S,." Renewal, <br />For License year ending June, 3110 <br />L Legal Name_ Ot <br />4. Date ofBirl, <br />5. Drivers License Number <br />6. Emal"I 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 X — If es, list, each name along with dates and places where used. <br />Name and address of'the liciensed Massage Therapy)Establi§h�aent that you expect to be employed bf. <br />Have you had any previous massagie, therapist license that was revoked, suspended, or not renewed? <br />Yes, No 2( if yes explain in detail. , <br />License fee is 100I.00 <br />Make checks, payable to City of Roseville <br />