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Attachment A <br />2. Home Address <br />3. Horne Telephone <br />4. Date of Birth <br />,8. Name and address of the licensed Massage Therapy, Establishment that you expect to be employed by. <br />9. Attach a certified copy of a diploma or certificate of'g,raduation from a school of massage therapy <br />including, a minimum of 6100 hours in successfully completed course work as described in Roseville <br />Ordinance, J 167 massage Therapy Establishments. <br />10. Have you had any previous 7�S�e therapist license that was revoked, suspended, or not renewed? <br />Yes No If yes, explain in detail. <br />License fee is 75.,oO <br />Make checks payable to City of Roseville <br />