Laserfiche WebLink
� <br />� <br />Finance Department, �,�c�ns� D���sia�n <br />26Ci� �nv�� Center Drive, ?,��s�v�ll�, �� ��1�� <br />��5�,� 792-7034 <br />���s���� '�����,p�s� ��ce�.�e <br />New License °' Renewal <br />For License year ending June 30 •� �' <br />.. f .��al �a�7C f��.� � � ����'��i�Ji� �i�� � � �� `� f I � r �E � <br />_� . , , .�_ . . •� <br />�. l�omr !�d{IT�s� r <br />a- <br />3. T-To�ne Telephone ' . N , , , � �. , , � , ? <br />4. Date of Birth <br />.. T _ � �R <br />5. Drivers License Number <br />6. �mail Addres��_ <br />7, [{�4�� vou ever used or been lcnown by any nanie other tl�an the legal name given in number 1 above? <br />Yes ... _ No If yes, list each name along with dates and places where used. <br />�r , ,� . <br />� ' .� f <br />�. 'i+T�17YC �YI� 8A�'.I i�4 nf �T}n a�,.�.. �� 11�a...J.�n T�.�.nr�y• FcrakJi chilhiwLt �F5�1'L ki1LL �i�BC� � �:';' C-�Gl�jr'�4� �1J. <br />+ � — <br />�y�C:�G�.`'._����Y_1�-„J�.3-r� �°'� ` •..J1.4n .■ ..aJJ _ , J'- � <br />��"�'�C�f �� ��.��� ��'� .� ��'��I��rp 4��y - ` t � <br />9. Attach a certified copy of a diploma or certificate of gradua ._.--,�. Ux ����-^� �fl�r�py <br />including a minimum of 600 hours in successfully completed course vvortc as described in Roseville <br />Ordinance 116, massage Therapy Establisl�ments. <br />10. Haee you l�ad any previous massage therapist license tl�at was revolced, suspended, or not ;re�.swed? <br />Yes �'�' If yes explain in detail. <br />License fee is 75.00 <br />Malce cl�ecics payable to City of Roseville <br />