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2. Home Aaciress ", " `1% 2 <br />.................... <br />C, - Home Te e]=- <br />4. Date of Birth <br />5. Drivers License Number- <br />61. Email Address <br />7. Have you ever used or been known by any -name other than the legal name given in number I above? <br />Yes, No, If yes, list each name, along with dates and places where used. <br />8. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />9. Attach a certified copy of'a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully complleted course work as described in Roseville <br />,Ordinance 116, massage Therapy Establi.shments. <br />101. Have y'olu had any previous massage therapist license that was revoked, suspended, or not renewed?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 />