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81 <br />Massage Therapist License <br />New License Renewal <br />For Licensc year ending June 30 <br />5. Drivers License Number <br />6. Email Address <br />7. Have you ever used or been n by any narne other than the legal name given in number I above? <br />Cs No If yes, list each name along with dates and places where used, <br />S. Narne and address of the licepsed Massage Thcr Establishment that you ex to be em ovedby. <br />#41 q, -^ 1 *1 <br />M a TK�?d— SA -SOCC Leea ncj\ <br />A, - <br />9. Attach a, certified copy of a diploma or certificate of graduation from a school of massage therapy <br />inclulding a miniinum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 11 ,6, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license ithat was revoked suspended, or not renewed? <br />Yes No, If yes explain in, detail. <br />License fee is 7'5.,O�O <br />Make checks payable to City of Roseville <br />