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9 <br />Massage Therapist License, <br />New, License, Renewal <br />4., Date of Bh-ffi <br />-- -- -- ---------------------- <br />5. Dfivers License Number, <br />6. Email Address <br />7. Have you ever used or been, known by any name other thm the legal name gften 'in number I above? <br />0 <br />Yes No If Yes, list each name along with dates and places where used,. <br />1 <br />8. Name and.address of'the licensed <br />ed <br />Massae Therapy, Establishment that you, expeict to be employ <br />g by, <br />9. Attach a certified copy of a diploma or certificate of graduation, from a school of massage therapy <br />including a minimum of 600 hours m" successfully completed course work, as described 'in, Roseville <br />Ordinance 11, 6, massage Therapy Establishments. <br />I <br />1041 Have you had any previous, massage therapist license that was revoked,i suspended,, or not renewed? <br />Yes No X If yes explam" M"' detail. <br />License fee 1,001.00 <br />Make c,hec�ks payable to City of Roseville <br />