Laserfiche WebLink
i. �W- �A%7� � MI k1 r <br />2. Home Address <br />3. Home Telephone <br />4. Date of Birth <br />5,. Drivers License Number--V <br />6. Email Address & <br />7. Have you ever used or been known by any name other than the legal name given in number I above) <br />Yes I No. z& — If yes, list', each name along with dates and places where used. <br />8 Name and addre used Ma a e Thor Py Establishment that you ex ect to be employed by <br />4 <br />04--A 0 r A <br />DLAS� <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 in successfully completed course work as described in Roseville <br />Oirdinancle 116, massage Therapy Establishments. <br />10. Have you had any previous ma sage therapist license that was revoked, suspended, or not renewed? <br />Yes No, — z: If yes explain in detail. <br />License fee is 75.1001 <br />Make checks payable to City, of Roseville <br />