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Attachment A <br />Massage Therapist License <br />............................... ......... . ........... . <br />.......... <br />. .... ....... ............... ............................... <br />New License Renewal <br />For License year, end m",g June 30 <br />1. Legal Name <br />2,. Home Address <br />3. Home Telephone <br />Date of irk <br />5. Drivers License Nu mbei <br />6. Email Address <br />. ................................................................................ <br />U ly <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />41 <br />9., Attach, a certified copy of a diploma or certificate of graduation, from a, school of massage therapy <br />r a 0 <br />including a minimum of 60�O holur�s in successfally completed course work as described in Roseville <br />Ordinance 1161, massage Therapy, Establishments. <br />I O�., Havie you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No If Yes, explain in detail. <br />tl <br />License fe is 100.00 <br />Make chec, payable to, Cift if'Rosevi,lle <br />V <br />