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a A <br />123L!= <br />'D <br />New License ixenewal <br />For, License year ending, June 30 <br />Legal Name- A(I' L! <br />27 , Home Ad,dre ,, <br />31., Home 'Telephone <br />4. D�ate of Birth <br />it <br />5. Drivers License Number, <br />6. Email Address <br />7. Have you ever used or be known by and name other than the legal nwne given M* number I above? <br />Yes No , X, _ If yes, list each name along with dates and places where used. <br />8 b emvloyed b <br />. Name and address ofthe licensed Massage, T herapy stablishment that y o u expect jo e <br />W(tv 14, X <br />1.2 Pa-9e CtP- 111i <br />9. Attach a certified copy, of a diploma or certificate of graduation from, a school of massage dierapy <br />A <br />including', a mm"inurn of 6001 bow *'in successfully completed course work, as described in Roseville <br />Ordinance 11, 6, massage Therapy, Establishments,., <br />10, Have you had any previous massage therapist license fliat was, �rievokeid, suspended, or not renewed? <br />Yes! No X1. If yes explain mi detelil., <br />License fee is 1010 001 <br />Make checks payable to City of' Roseville <br />