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Attachment A <br />f Ar <br />Finance Department, license Division <br />2660 Civic Center DAve, RosevAle, N 55113 <br />0792-70M <br />Massage Therapist License <br />New LktTw 7K Renewal ❑ <br />ror Liceme yea endkq June .30s <br />1. � I NJWM 'z-11/2 CA -t-- <br />0100 Ha= Add <br />rss <br />I Hoare Tekpbonc - <br />4. Date ofBirth <br />5. Drivers Liceme Number <br />6. Address <br />7. Have vu ever used or been known by arW nmr oflxT rhe leeal nanr gh7en M nuntxx I above? <br />Yes 'No If ves . Ust each bane alo rw w ith date s m-A n Jacr is wl-& re nsb <br />i <br />8. N and css ofdr licensed MasW Tt=WY,, Estab%iftnmt that y1pu pert be mvia d by- <br />(2 UA-42 all toe rj:6 lea SSA3 <br />-w <br />us Have you had apypm-wus rmssage them ist Femse t was re%vked- suspended, or not remwed' <br />Yes El No Syes, explain in detail on a separate page. <br />Please P, ria this fe-rmand rmitor hmnd-de&vr abng with a cmTicd wff of a dutLarm. crcatfizvx or <br />waduation from a s boo lofmassapt therapy itic a rt*jmumof600 bours M SWZC&SR�• conOw <br />course work as described in.Rosevffle Ordkiame 116, M ass Therapy Estab %lurrnts. <br />F I-lame -.Depaitrrnt Lice= Div b"W'n <br />1660 Cbv* Center Drive <br />Liceme fee is $106.00 <br />Niake checks p yabt to: City ofRoseNr-Uk <br />*9 <br />