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Attachment A <br />Massage Therapist License <br />W <br />Aome Address <br />C. Home Telephone <br />4. Date of Birth <br />5. Drivers License Number <br />6. Email Address <br />7. Have you ever used or beep kmoWn by any name other than the legal name given in number 1 above? <br />Yes No r If yes, list each name along with dates and places where used.6 <br />9,. Name and address of the licensed Mrag� Therapy Establishme <br />V that you expect to be employed by, <br />5. Attach a certified copy of a diploma or certificate of graduation from a school of massage therapy <br />�ncluding a minimum of 600 hours in successfully completed course work as described in Roseville <br />41r1 inance 116., massage Therapy Establishments,, <br />(0. Have you had any previous mmsapre, therapist license that was revoked, suspended, or not "'II <br />? I Nexplain in detailt <br />Ilcense fee is 100.00 <br />Make checks payable to City of Roseville <br />