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mi. <br />Massage Theraplist License <br />....... ... . <br />............................... .... ............ <br />New License Renewal <br />Ai <br />For License vear ending June 30 <br />1. Leg-al Miji-ic Jo Ap�je--Map-ta <br />2,, Homic Addi-css r ZZ, <br />3. Home Tclici.)[ione <br />4. Date oil-'Birth ./ %- .4 <br />5. <br />Drivel -s Liciciise Number t-- � ja-. -0 <br />J <br />61. Etna'] Addricss <br />7. Have �.-OU ever rased or been known by any narne other than the legal name given in inimber I above? <br />Yes —X - No If yes, list each name along with dates and places where used, <br />I <br />84, Name aiid acidress of the licensed Massage Therapv Establishment that you ct to be employed by. <br />2- 0 <br />B MO, <br />9. A mac 1i a c.eri I Fied copy of a diploma or certificate of graduation from a school of massage therapy <br />iii,cluding �i im I n I imuni of 1600 11ours 11i successfully completed course work as described in Roseville <br />Ordinance 1 16, niassage Therapy Esti,iblishments. <br />10,, Have you lizid atiy previous massage therapist license that was revoked, suspended, or not renewed9 <br />Yes No - -;>< If yes, explain in detail. <br />License fee, is 75.,00 <br />Make cliecks payt-ible to City of Roseville. <br />