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� ��� � <br />. ����. <br />Finance Department, License Division <br />2660 Civic Center Drive, i�.a�evi�Ie, I�i1� 55113 <br />(651)792-7034 <br />�'� ����g� '�`li�r�pi�t Li��r��� <br />�, - - _ _ -- .�. <br />New License Renewal <br />For License year ending June 30 �'� �� <br />5 ' <br />]_ ����� �a`i' `J• `��+ ;�!y��.���'� `'� Y� _ —.. • —���.r <br />.�` <br />� � �� �� � � . . . , i <br />�. }�OrTIIC .itiL��ss _ _ t-.� — . . � <br />3. Home Telephone � - � <br />4. Date of Birth <br />� , � <br />5. Drivers License Number <br />6. �mai� Address <br />7. Ha�e you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes No � If yes, list each name along wi��� dates and places where used. <br />8. Name and address of ti�e licensed Massage Therapy Establishment that vou expect to be e�m{ployed by. <br />�-�J-��� }�i+.:-_�.�� 1�"��{x � ] r,f�-£ ��•� �� ��,[� �� I.�lt^'f�i <br />9. Attach a cer�i�ec� copy of a diploma or certificate of graduation from a school of massage therapy <br />including a minimum of 600 hours in successfully completed course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. <br />] 0. Ha�e you had any previous massa�e therapist license that was revoked, suspended, or not renewed? <br />Yes �� . � If yes e�plain in detail. <br />License �ee is 75.00 <br />Malce checics payable to City af Roseville <br />