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3. Home Telephone <br />4., Date of Birth <br />5. Dr,ivers, License Number <br />01, Einall Address <br />4 <br />7. Have you ever used or been known by any name offer than the legal name. given in. number I above? <br />Yes No X - If Yes, list each name along with dates and places w1are used. <br />I hat was rievoke <br />10�. Have you, had any previous ssage therapist ficense t d, suspended, or not renewed? <br />Yes I No-5� If yes explain, in deitai'l. <br />License fee lis'71,5.00 <br />Make checks Payable to, City of Roseville <br />