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Massage Therapist License <br />................... <br />.... ....... <br />.............................. <br />New License Renewal <br />For License year ending June 30 =,2on <br />L Legal Name � V-- ( CAJU <br />2. Home Address <br />3. Home Telephone I V-1 <br />4. Date of Birth -1 1 ; <br />5. <br />31 <br />Drivers License Number — <br />Email Address— <br />T Have yoll used or been known by any name other than the legal name given in n. mber I above? <br />Yes No If Yes, list each name along with dates and places where used. <br />A <br />8i. Name and address of the licensed Mn.S.Sage I herapy Establishment that you expet; 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 completed course work as described in Roseville <br />t <br />Ordinance 116, massage Therapy, Establishments. 0 V\ � � 1,6 <br />0 US 0 <br />10. Have you had any previous m"e therapist license that was revoked, s pended, r not renewed?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 />