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New License <br />For License year ending, June 30 <br />J <br />I., Legal Namejy//00-4&— <br />Renewal Y, <br />. El <br />FA n4w a, <br />2, Home Address <br />3. Home Telephone <br />4. Date of Birth <br />51. Drivers License Number 0 1 1 <br />6. Ernail Address <br />7. Have vou ever, used or been kn7n by any name other than, the legal name given in number 1 above? <br />Yes No f yes, list each name along with dates and places where used. <br />8. Na e d a <br />ddrPs of the licensed Massage Therapy Establishment that you expect to be employed by. <br />9 1 <br />Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a mini mum i <br />of 600 hours n successfully completed course work as describPO in Roseville <br />Ordinance H 6, mas,sage Therapy Establishments. <br />f <br />10. Have you had any previous rnas3ekl-e-""therapist license that was revoked, suspended, or not renewed? <br />Yes Nol – If yes expilain in detail. <br />License fee is 75.00 <br />flake checks pay'ablle to City of Roseville <br />