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New License Ve, 5 Renewal <br />For License year ending June 30 <br />1. Legal Name <br />2. Home Address, <br />J. Home Telephone <br />--- ------------ <br />5. Drivers, License Number <br />6. rnail Address <br />7. Have you ever used or been known by any name other than the Regal narne given in number I above? <br />Yes No, if yes, list each name along with dates and places where used. <br />Z is 1 <br />f andl address, 0 e licensed Massage Therapy, Establishment that you expect I-o be employed bt}. <br />.1 <br />--e /W. <br />9 <br />91. Attach a certified copy, of a diploma or certificate of graduation fron-i a school of massage therapy <br />including a nninii-num of'1600 hours in successfully completed course work as described in Roseville <br />Oirdinanc,e 116, massage 'Therapy Establishments. <br />1, 0., Have you had any previous massage therapist license that was revoked, suspended, or not renewed?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 />