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Oi <br />Massage Therapist License <br />New License Renewal <br />For License year ending June 3,10 looOi <br />ill Yq1/ WYtlh1U�11) W�IIpI�YtlU) IYtlAVI1WIWIWIWIWYlIIYIIYIIYIIN: <br />I Legal Name <br />2. Home Address <br />3 Aom,e Telephione <br />%Nor <br />4. Date of Birt? <br />8. Niame and address of the licensed Massage Therapy EstiLbill'shment, You expect to be mployed by. <br />srs, <br />rap v- V U — t Vo — � — <br />41 <br />9. Attach a, certified copy of a, dipilloma, or cenixicutt; ul, 8inuummu uvit, a ochool of massage therapy <br />including -0 0 <br />including a, minimum of 600 hours, in suc�cessfu,lly completed course work as described in Roseville <br />Ordin"ance 116, massage Therapy E,stablish,men�ts. <br />10. Have you had any previous is,age therapist license that was, revoked, suspended, or not renewed? <br />Yies, No, F If yes explain in detail. <br />L 10 <br />i I icense fee is I O�101.00 <br />City Make checks, payable to City of'Rosieville <br />