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Attachment A <br />1�'� <br />. <br />�.�.�._ J , _...._ 1 � 1 <br />�'inance ��pa�ment, Liceuse Division <br />2660 �'ivic Ce��er Dri�e, Rosev�lte, N�Iii 55i13 <br />(651) "192-7036 <br />�Iassage 'I'herap�st I.icense <br />New Lieense %� Renewai <br />For License year ending June 3� <br />I /�� P <br />1. Legal Name ��J'�{ �O�iP V1 l"�c '�Q11 <br />2. Home Address . . . . . ..� , . , .1 <br />3. Home Teleplzone , . , � � • . , � <br />4. Date o€ Birth <br />5. Drivers License Number ._. � <br />_�... � ��__� �_ a�-�„�_�.�r <br />I._ ._ ._._ _�.. _ .. _, <br />6. Ema.i1 Address <br />7. Have you ever used ar been knawn by any name other than the Iegat r�ame given in nu�nber i above? <br />Yes No __� If yes, I.ist each name aior�g with dates and ptaces where used. <br />8. Narrie and adc�ress of the li ensed Massage 'T�era y ablishment that you expect ta be eEn loyed by. <br />� r � � u � � c� Gt l� � �2 �! 7 f `�- fn � �V , <br />�o��;((�+ M SS(�3 <br />9. Attac3� a cefifed cogy of a dipiama or certificate nf graduation fram a school of massage therapy <br />incluc�ing a�a�inirs3um of 6QQ hours in successfirlly completed course work as described in Roseville <br />Qrdinance 116, massage Therapy Establistunerrts_ <br />t 0. Have you ha,d any previous massage therapist licer�se that vvas revoked, suspended, or not renewed? <br />Yes No � �f yes expiain i� de�l. <br />License fee is 75.00 <br />Make checks payable to City af Roseville <br />