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2008_1020_packet
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2008_1020_packet
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2/15/2012 1:34:48 PM
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Attachment A <br />r vaassage'therapist License <br />New License Renevtral <br />i <br />For License year ending June 30 <br />L Legal Name If X1 Ir"D i U 14 &T2 kis 6 0 <br />• Home, Adidresis. <br />Home Telephone <br />4. Date of Birth <br />5., Dii.vers License Number, <br />6. 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 />10. Have you had any previous npssage therapist license that was revoked, suspended, or not renewed? <br />Yes No Ifyes explain in detail. <br />License fee is 7'5.00 <br />Make checks payable to Cit), of Roseville <br />
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