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� � <br />��� w � � � 1 .� <br />� <br />Finance D�gaartrrent, I� L�v►�►rn <br />2660 C:�vi,c �����e° L�ive, Ra�s��i���, NT�T 55113 <br />(651) 792-7034 <br />� �s� ��� -l' �� �ra �� a �t I�i r�n�� <br />New License Renewal <br />For License year ending June 30 �--�� � <br />1. LegalName��.�^..d�'7'.1_ .� ..�:..�_t7_��� <br />.. � <br />2. i-ior�se Address _ _ . . . _ <br />3. Home Telephone <br />4. Date of Birth . __ . _. <br />5. Drivers License Number _.. v s- r. ..l � <br />6. �'�nail Address . _ � , �,r f � . , v- , <br />7. Have you ever used or been lcnown by any name other than the legal name given in nui�nber i above? <br />Yes No }� Ifyes, list each name along with dates and places wl�:re used <br />8. Name and address of the licensed Massage Therapy rs«Er]isfir��en� tl�a� }•�u ��,e�i �u Ue �i�ipluj����cl bM1y_ 7 <br />__� f• � �7 4' ' G• lh t �ti ��F� _ ''� i � 7� /' _, ��'-�7P �.Z�� ���rL�d_�� y�' c1� ���[ � f �� � <br />�%r� "�j .��'�L�J �� � �ry � ,�� . �'Y' 1 ��i� � � � ��� <br />9. Attach a cei-�ifiec� copy of a,dip�orna or certificate of graduation from a school of massage therapy <br />including a minimum of600 hours in successfully con�pletsd course work as described in Roseville <br />Ordinance 116, massage Therapy Establishments. � l� �— ��. �� <br />i p. Have you had any previous �*+�� therapist license that was revolced, suspended, or not renewed? <br />Yes— —�''� — ifyes explain in detail. <br />License fee is 75.00 <br />Malce checics payable to City of Roseville <br />