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My <br />New License Renewal <br />For License year endue"g June 310 1. 01 ij --z- AMNN40NUNHN4WWVN-911 <br />L Legal Nmie- �A'� a�- f. -Q <br />2. Home Address <br />3. Home Telephone <br />5., Drivers License Number, <br />61. Email Address <br />a v <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 />8. Name and, address of the licensed, Massage Therapy Establishment that you expect to be employed by. <br />P, <br />91. Attach a, certified copy of a d1pillorna or certificate of graduation from a school of massage therapy <br />including a, rnin of 6010 hours in successfully, completed, course work as described in Roseville <br />Ordinance 1116,1 massage 'Therapy Establishments. <br />10. Have you. had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No I X If yes, explain in detail,., <br />ir <br />License fee is 100-00 <br />Make checks payable to City of Roseville <br />