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� <br />� � <br />Finance ilep�r�m�n�, L���aa�e Div�s�o� <br />2660 G�va� Cent�� D�iwe, Rvs�v��l�,1VIl� 5�113 <br />(6�1j7�2m7D34 <br />�a���.�� '�"her���s� I��cen�e <br />New �.icea�se Re�newal � <br />�'or License year ending June 3� <br />1. i,eg;al Name � � �= <br />2, Home <br />3. Hnzr�e '�'elepk�or�e <br />�. llate of Bzrt�► <br />� � �i �...,�-..� ,, � <br />-'• r +�i '—! `.: d `�?! v — 1 s 'I' ' -,- . . <br />5, D�vers License Numbe� , K-� <br />6. Email Address <br />7. Have yau ever used oar beez� �nown by any name other than ti�e legal narne giv�n in nuzzaber 1 above? <br />Yes _,.. _ No _ _ If yas, fist each a�ame along with dates and piaces where useci. <br />and adrlress of the lieensed Massage The <br />v`� YZ ��I � 1� r,i r°, i� J,� n� <br />you �x�ect tp be �mpinyed by. <br />;,� .-� t� 3 1 l�P f'V1 �� 5 5/ J� <br />9, Attach a certified copy of a dipivma or certifieate oi graduatinn froana a sc�oal o�'�zzassage therapy <br />including a minirnum of 600 haurs in s�ceessfully cQZnpleted ca�sa woxk as deseribed ira KosevilIe <br />Q:rd'zna �ce 1 l 6, rnassage 'i�iarapy Estabiis%�enis. <br />1€i. Have yo�z had atry prevzous an�ssage therapist l�eense that was revoked, suspended, or not renewed? <br />Yes` � No _ � Iiyes expla� in� der�il. <br />License €ee is 75.0� <br />Ma�ce c�ec�s payable to City of RQSeville <br />�1 l �? (J � ��. �7 ` d��.. <br />