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1 ����..' <br />�. <br />Finance Department, License I)avisi�� <br />2660 Civic Center Drive, Roseville, I�iA' �� l i� <br />(651) 792-7034 <br />1�I�����c� T�Y�r�pE�� �i��r�s� <br />New License �:f Renewal <br />For License year ending June 30 `a� ��'�-�' � <br />4' � j • <br />,.. �, � <br />1. Legal Nazne ��'"� � °,� �ti `������, lf���f�_ ;'� r� � ~-� <br />2. Holne Address I • __. ,•.�; <br />i� <br />3. Hoine Telephone_� _ <br />4. Date of Birth <br />5. Dzivers License Number <br />a. � _ <br />6. Email Address ��. <br />� <br />7. Have you ever used or beer known �y name other than the legal name given in number 1 above? <br />Yes _ —�� � _ If yes, list each name along with dates and places wl�ere used. <br />8. Name and address of the ";• •:• •�cr{I_'ti f.�wsage Therapy EstablisL• :: ��•�� � il;n� yti i �spt�•� �L� C+� �_i q�Iti•yt•,� I�p <br />����.ti �: -� �x���}_ � � ��C����-k �� <br />� <br />9. Attach a certified copy of a diploma or certificate of graduation fiom a school of inassage therapy <br />includiilg a minimiiin of 600 hours in successfillly completed course work as described in Roseville <br />Ordinance ll 6, massage Therapy Establislunents. <br />10. Have yo�i had any = �.• �. ���� � �• �:� �_. ��� therapist license that was revolted, suspended, or not renewed? <br />Yes No __ y� If yes explain in detail. <br />License fee is 75.00 <br />Make checks payable to City of Roseville <br />