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�. ����� . <br />�}.� � � , � � � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, �i�T ��i13 <br />(651) 792-7034 <br />�s�a�� T!� er��ist i� r�}�n�� <br />.\,, <br />New Lice��se '� Renewal <br />For License year ending June 30 <br />;•� _ �`� . <br />,- ,, .- : <br />' { �S� �. .,,�r � . ' � i��'-'`�'� <br />1. Legal Name L `� �.��4 �C� �'�� � ' � ' • L_ <br />2. Home Addres _,� .� <br />3. Rome Telephor <br />4. Date of I�i; ,�- <br />5. Drivers License Nurn� <br />�. Ema;f �d�re <br />� � . <br />� <br />'�, Ha�rc 3-,. <br />Yes �'r used or�en� by any name other than the legal name given in number I above? <br />Tf yes, list each name along with dates and places w�aere used. <br />.� <br />�� . <br />.�_.-- � _ _. __}.:_ � . _ <br />� <br />�. � _ c �ii� � ss 0 1Ei� r��.,i�d'FrTasaerg��h�r�}'F��h1�K�:;�eui �haR� �� exp�� � �rr�p . <br />. � �L_. � � � ���si; ' �����5� I � , Y'�. �� <br />9. Attach a certified copy of a diploma or certificate of graduation f.-��ir_ 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 Establishmeuts. <br />If?. Have you had any �•«•ti•� �� ��4� therapist license that was revoked, suspended, or not renewed? <br />Yes �Tc _� If yes explain in detail. <br />License �ee is 75.00 <br />Male checks payable to Ciry of Roseville <br />