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For License year ending Juile 30 <br />C)9 <br />A <br />1. Legal Narnie -N - "11 - L-41 <br />2, Honne Address <br />3. Horne Telephone <br />4. Date of Binh <br />5. Driver's License. Nuniber--=, <br />61. Email Address <br />7'. Have you ever used or been known by any narne other than the legal name given in number I above? <br />Yes, No ve' If yes., list each name along with dates and places where used. <br />S., Name and address of the licensed Massage Therapy Establishment that you expect to be employed <br />,Se re v-, xv L 1 <br />9, Attach a, certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimurn of 600 hours in successfully completed couirse, work as described in Roseville <br />Ordinance 11 6, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed?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 />osL v; 1 � � �'l� <br />s� �a3 <br />