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Attachment A <br />New License <br />Renewal <br />For License year ending, fune 30 <br />1 . Legal Name CX--,) 'L'C'rY-)CY-C'—' <br />2. Home Address- <br />0 9 .1 <br />4, Date cif B1rth------- <br />5. Drivers License Mmber <br />6. Email, Aiddres <br />T Have you ever used" or been k 7 W "I <br />anv <br />n by 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 />-.' S., warm F,'and address the licensed Massage Therapy Establishment that yop ex ect. to be employed by. <br />d-4 �'- <br />9. Attach a certified copy of a diploma or certificate of g,raiduation, from a school of massage therapy <br />including a, mi um. idin inim of 600 hours in successfully completed course work as described in Roseville <br />Ordinance, 116,, massage Therapy Establishments. <br />101. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No If yes explain in detail. <br />License fee is 75,00 <br />Make checks payable to City of Roseville <br />=3 <br />