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Massage Therapist License <br />2, borne Address- <br />3. Home Telephont-,_ <br />4, Date of'Birth _j <br />5. Drivers, License Number <br />61. En-iail Address- <br />71. Have y � ever used or been kn w ny n by a name other than the legal name given number umber I above? <br />1%, ? <br />Yes No, If yes, list each name along with dates and places where us-ed.. <br />8. Na e an ad ess Of the, licensed Ma erapy Establish that you. expect to be employed', by. <br />z' t slit 1� go <br />A <br />91, Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />i <br />including a minimum of 6100 hours in successfidly completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments, <br />11 . Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No, if yes explain in detail. <br />—7%----- <br />License fee is'75,00 <br />Make checks payable to City of Roseville <br />