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fa <br />Massage Therapist License <br />New License x Renewal <br />For License year end m'g June 30 ZV 12- <br />1. Legal Narne ZOO C,44- Z20 Xo,-1,LZ &, <br />2. Home Address -'Now <br />3. Home Telellf=- <br />4. Date of Birth_ <br />5. Driyers License Number_ - I <br />6. Email Address <br />12 <br />7. Have you ev used or been known by any name other than the legal natne given in nwnber I above? <br />Yes No If yes, 11st each name along with dates and places where used. <br />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes No Loo� _ If yes explain in detafl, <br />License fee is 100.00 <br />Make checks payable to City of Rosevilil <br />