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.�'� ���,_..� <br />��f��'�� <br />���� , <br />� <br />�a����� Department, License Division <br />2�&� Civic Center ��r���, R[��������q 1V�IiT 551�3 <br />(6�1� 792-7034 <br />i������� Therapist �ac�n�� <br />New License Renewal <br />�7 <br />For License year ending June 30 �:� ._ <br />Legal Name � �� l}� <br />A . s, 4i x 11 <br />2. �-�ome Address <br />3. HomeTelephone� <br />w <br />4. Date of Birth <br />5. Drivers License Number <br />6. �az�ail Address <br />7. Have you ever used �r �eo�G k���y��, l�}� any name at(�ter 1Tiart [Tic legal nai'�7e given in i�u�nber 1 above? <br />Yes �It� � If yes, list each name along with datea and places wE�ere used. <br />� -- <br />8. Name and address of the licensec� T�1sss��t+. Therapy �stablisht�ne�it that you expect lo be cEnployed by. <br />� k fi��'� �` JS�. �'�,� ' <br />9. Attach a certified copy of a diploma ar certificate of graduation from a school of massage therapy <br />includiug a tninin�uzn of 600 hours in successfully completed course wark as described in Roseville <br />Ordinance � 1 G, massage Therapy Establishments. <br />10. Have you had any �7�.��ious rnaas therapist license that was revoked, suspended, ar not renewed? <br />'Yes Nc� �. If yes explain in detail. <br />License fee is 75��#�� <br />M�1ce clzectcs ���f� to City of Roseville <br />� � <br />� <br />