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New License <br />For License year ending June 3 <br />1. Legal Name <br />Home Address <br />3. Horne Telephone <br />4. Date of Birth <br />Renewal <br />w .1(A <br />Drivers License Number <br />6. Eniai l Address ajj, <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 If yes, list each name along with dates and places where used. <br />8. Narne and address of the licensed Massage Therapy Establishment that you expect to be employed . <br />F � � -5 -y't3 <br />. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 1 1 , massage Therapy Establishments. ,. jo L, kze-e &vn Pt <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed?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 75.00 <br />Make checks payable to City of Roseville <br />