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Massage Therapist, License <br />(Please Print Clearly <br />New License ❑ Renewal <br />For License Year Ending June 30, <br />G1. Full Legal Nam (Please Print) � ! - - -- - -- hZizi eo req I f) Q, <br />Last (First) MINd die} <br />2. Home Address- <br />3. Telephone <br />(Street) AN- (State) (ZIP) <br />4. Date of Birth m n dd�yyyy _ <br />5. Driver's License Number <br />6. Ethnicity: <br />7. Sex <br />ell ❑ Home ❑ Work <br />Stag of Issuance Ow <br />8. Email Address <br />9. Have you ever used or been known by any naive other than the legal name gi ven in number I above? <br />❑ Yes No If Yes, List each full naive along with dates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishment at which you expect to be employed: <br />, V_% V00 5NUu t , N <br />Lpn%.Q yy+-s rn cAssu ci�z A� <br />41 - <br />I I . Have you he Id any previous massage therapist licenses`? I f yes, 111 h C h city were you licensed? <br />❑ Yes o <br />121. If you ans wered Yes to number 1 I above, were any prey ious massage therapist I i c enses revoked, suspended or <br />not renewed"? <br />❑ Yes ❑ No ❑ ,- <br />Ifyes, explain in detail on a separate page. <br />By signing belo w you cert if , that the above information is correct and authorize the City of l osev i I le Police <br />Department to run our information for the required ba grt'ot :nd checks. <br />Signatu - - - Date <br />Please print th and mail or hand - deliver along with a certified copy of a diploma or certificate of graduation <br />from a school of massage therapy including proof of a n7 iniinurn of boo h urs in successful ly completed course <br />work as described in l oseviIIe Ordinance 116, Massage Therapy Establishments. <br />License Fee is $100.00 <br />Make checks payable to: City of Roseville <br />