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New License Renewal <br />For License year ending June 30 <br />L Legal Name j Ld I � -OX-L4 e, n '() t <br />Ir <br />2,. Home Address r— - - 11 IJ <br />4. Date of Blirth W4-10W — r- — <br />5, Drivers License Number � lmbftw <br />6. Ema,i'�l Address W a <br />7. Have you ever used or been known by any name other than the legal narne given 111 number I above? <br />Yes No If yes, list each name along with dates and places where used. <br />t, Name and address of the licensed Mass Therapy Establish t you expect to b loyed by, <br />U 33, a A- W =r LT <br />9. Attach a, certified copy of a diploma or certificate of graduation from a school of massage therapy <br />inClUding, 1:) a minimurn of 6010 hours in successfully completed course work as described in Roseville <br />Ordinance 11611) massage Therapy Establishments. <br />10. Have you had any previous rnassage therapist license that was revoked, suspended, or not renewed?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 />