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New License <br />For License year ending June 30 <br />1. LegW Narne D <br />3. Home Telephone <br />4. Date of Birth <br />5. Drivers License Number <br />Renewal <br />6, F4nW*I Address I-" - V V V I * - . - 1 0, W V.,* 1, - " P... ,V %, , ' ' k <br />-op <br />7. Have you ever used or been known by any name other than the legal name given M number I above ? <br />Yes If yes, list each nme along 14q"th dates and places caber used. <br />S. Name and address of the licensed Massage 7herapy Establishment ftt You expect be employed by. <br />a a. <br />V RM <br />9. Aftacb a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />se work as describedmi Roseville <br />including a mh 'mum of 600 hours m* successfully completed cour, <br />Ordinance 116, massage Therapy Establisbments. <br />10. Have you had any previous massage therapist license that was revOked, suspended, or not renewed? <br />Yes No — t1_111- , If yes explain 'M' detail. <br />License fee "is 75.00 <br />-N4ake checks payable to City of Roseville <br />