Laserfiche WebLink
���� -, � <br />,�►_� � , �.. � �_ � <br />Finance Department, License Division <br />�� Civic ���n��a� Drive, �.os�vi�l�� 1��T ��1 l� <br />(&��� 7�3-�i��� <br />�f������ �i���a�i�# �:������ <br />New License Renewal <br />x� <br />For License year ending June 30 .� �� v <br />� . Legal Name ���'� �: �� �� �✓� � <br />?. Home Addr�ss <br />�. Home Telephone <br />��. DateofBirth •f. . <br />�. Drivers License Number — � � <br />�i. Emai1 Address ' <br />,� - - - <br />-. Have you ever used or been �Cnawn by any name other than the legal name givem m �umber 1 above? <br />./ <br />YPS i� U iL �1� yeS, iis[ �.dl:i� ridtiiL' aiV1�� n � i� � dat,�S IRIL,I j7��6c3 W�fiBi� uS��. <br />R. Name and address of the licensed Massage Therapy Establishment that yJou expect to be employed by. <br />5� �L• �t Tt �r.r�l� J��%� G G. � <br />7 <br />�;. Attach a certified 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 />10. Have you had any previous massage therapist license that was revoked, suspended, or not renewed? <br />3� ��ti � If yes expl�in in de�-aai. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />