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��� � . ...� .� <br />�`��a��� ��p��•����a��, �.���a�s� ���r����a� <br />266� ���rA� ���i:�� �tt�a�r�, �cas����I�, �� ���13 <br />�5�1� �9�—�03� <br />l�a����� �"�������� ������� <br />New �,icer�se Rene�ual �� <br />T'o�• I.,ice�3se year ei�ds»� 1uf�� 3(3 _�SZ� <br />l. L�gal Na�r�e� ��r,,.r�,,.,��, 1�- f.lY <br />� _ , <br />2. Hoi�e Add►•ess ,. _ . . ..__ � .� _ . __ <br />3, Ho3r�e Te€epho3te <br />4. DaYe of I3i��tlz <br />5. Ds•ivers License NiE��-��er <br />G. �mai� �ddress � �,.. <br />7. Have yau ever �sed ar beeE� �Cr�aw� by any narne ather than the le�ai �3arne give�t in n€�r�ber � above? <br />Yes _ Na _ . if y�s, list each name along with dates and pEaces ruhere used. <br />8. Na e an ac(dress akf�Ylae liee�ised Mas�sjage T�erapy Es�blishmen� �E�at ynu ex�ec£ to !�e employed <br />� '� \i � "Y�,� � `€ C1C 4 ✓ c, U��-�� �...,�� .f ?% � <br />9. Attach a cer�i�ed copy af a dipJo�na or certi�cate of araduat'son f�•om a scl�ool of �nassage therapy <br />ia�cl�ding a�r€i�ti�rtum af Gt?0 hours ia� successfully completed course wos•k as desc�'ibed in Rosevilie <br />Qrdinance I f6, rr�assage'['herapy �stak�lish�r��t7Ys_ <br />] 0. 1-�av� you had any previous rs�assage therapist [ECeEise that w�s eevpked, susper�ded, o�• €ZOt re�lewed? <br />Yes� � No �� _ if yes �xplai« i�t detail. <br />I,ice��se fee 'ss 75.Q� <br />Ma�Ce chec�CS payable to City of E�aseville <br />