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���� <br />,� J . _ 1 � � <br />Finance Depa�t�nent, License Division <br />266fl Civic Cen�er Drive, Roseville, N�N SS113 <br />��s�� �9z-�a�6 <br />IVlassage Therap�st License <br />New License <br />Renewal -� <br />For E,icense year ending .Tune 30 ��C/ �d � <br />1. Legal Name _�1Jr'Gti^� C� ���n—� <br />2. Home Address �� � ( V �.�' C,�„i _)� � � /� !j� �� � � <br />3. Home Te[ephone <br />4. Date of Birth <br />S. Drivers License Number <br />0 <br />b. E�nai! Address <br />7. Ha�e you ever used or been known by any name other than the legal name given in number � abave? <br />Yes No �� If yes, list each name a]ong with dates and places where used. <br />8. Name and a�dress oi <br />�age Therapy Establishment that yo� expect t be <br />L1.-(' _ 1C, � �i �e � �- C��� , �-.� ��. <br />9. Attzch a certified cogy of a diploma or certificate of graduation frorrt a school of massage therapy <br />inclt�ding a mini�num of 60E� hours in successf�l3y cor�pleted course work as described in Roseville <br />OrdinaRCe t 16, massage Therapy Establishments. <br />by ��2, �+V <br />��� � <br />��3 <br />10. Have yo� had any previous rnassage therapist iicense that was revoked, suspended, or rtot ren.ewed? <br />Yes No � [f yes explain in detaiE. <br />i,icense fee is 75.00 <br />Make checics payable to City of Roseville <br />