Laserfiche WebLink
New License - -e-' � Renewal <br />For License year ending June 30 4p, <br />I LeGal Name <br />2. Home Address- <br />3. Home Telephone- <br />4. Datc of Birth t <br />5. Drivers License Number- <br />6. Eniail Address— ' e- <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 Jf yes, list each name along with dates and places Where used. <br />'-slame and address of the licensed Massage Therapy Establishment that you expect to be employed by,, <br />9. Attach a certified copy of a diplorna or cortificate of graduation from a school of massage therapy <br />including a minimum of'600 hours ill Sucic-essfullY completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not rcncwed"� <br />Yes No <br />If yes explain in detail, <br />License ee is 75,00 <br />Make. checks payable to City of Roseville <br />