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Massage Therapbt License <br />'New, License 22 Renewal, <br />For License Year ending June 30 2 <br />0. �Z <br />I Legal Name <br />I Home Address <br />3. <br />Home Telephone <br />4. Date, of Birth. <br />Drivers License Number, <br />6., Emal"I Address <br />4 W- <br />7. Have you ever uwd or been known by any name other than the legal name given, in number I above? <br />yes No >C) If'yes, list each name along with dates and places where usa' <br />f <br />8. Na me and address of the licensed M�assage Therapy Establishment that you expwt to be employed by. <br />1A IL < <br />9. Attwh a certifled copy of a diploma, or, certificate of graduation from a schooI of massage therapy <br />A 0 N <br />i I ncluding a mi i nunum, of 600 hours, 'in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy, Establishments. <br />I G. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No If yes explain in detail., <br />License fee is 100400 <br />Make checks payable to its of Roseville <br />