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*I <br />Massage Theraplist License <br />New License Renewal <br />For License year end June 30, <br />A 1. <br />I Legal Name Y1 /7 b U <br />2. Home Address <br />V <br />3. Home eleplbone ,_ <br />5. Drivers, License Number <br />61. Email Address <br />7. Have you ever used or bmn known by any name other than the legal name given in number 1, above? <br />Yes No k-'� If Yes, list each nee along with dates and places where used. <br />Name and address of the licensie 'Massa <br />.ge Thervy Establishment that ru ex ect to be employed b <br />'X <br />Zia XIIdu L ye= Kj< <br />9. Attach a certified copy of a diplorna or certificate of graduation from a school of massage therapy <br />6 <br />including, a minimum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 1116, massage Therapy Establishments. <br />1 10. Have you had any previlous, e therapist license that was, re�voked, suspended, or not renewed? <br />Yes No M137s If Yes explain 'in detail. <br />License fee is 75.00 <br />Make chiecks payable to City of Roseville <br />