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Massage Therapist Licens4 <br />New License Renewal <br />For License year ending ', June 30 <br />1. Legal Name <br />(- z r� 5�.1 <br />I A. <br />7. Have you ever used or been kn ► wn by any name other than the, legal name given in number I above? <br />Yes No . Z- —1 If yes, list each, name along with dates and places where used. <br />10. Have you had any previousrsage therapist license that was revoked, suspended,, or not renewed? <br />Yes No, If yes, expilai,n in detail. <br />License fee is 100.010 <br />Make checks payable to City, of Roseville <br />