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'd License Massage Therapist, <br />3. Home Telephone <br />Date of'Blirth <br />51. Drivers License Number <br />6. Emai I 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 too"' No If Yes, list each name along with dates and places where used. <br />AdAil.-�u f 6�7419ZZI <br />8. Name and addr,ess of the licensed Massage Therapy Establishment that you expect to be employed by, <br />t <br />--1/ - jV- <br />C��&� A <br />J, <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 completed course work as described In Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous mas e therapist license that was revoked, suspended,, or not renewed?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 />