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Attachment A <br />�� - <br />�� � . <br />Finance Department, Lice�se i)ivisio� <br />2Cr60 Civac Center ��-ive, Rosevil��, M�li 55113 <br />(6S1} 792-7036 <br />Ma�sa�e �'herapist L,�cen��e <br />New License � Renewal <br />For License year ending June 30 _�G� �Q <br />1. i,egal Name (/G� 1(l/V % •� mLLi � L� `'7`�U5 La �'l�' � � � . ..--, - <br />2. Home Address <br />3. Home Telephone � <br />4. Date of Bird� <br />5. Drivers License Number <br />6. Email Address <br />� <br />7. Ha�e you ever used or heen lcnown by any name other than the �egal name given in number 1 abo�e? <br />Yes �,�_, _____ No ifyes, list eac� z�ame aiar�g with dates and places where used. <br />_ r ` _— ,----.— _ <br />, <br />aJ . .� - - - <br />$. �Iame and adclress of the licensed Massage <br />- J <br />istunent ihat you expect to be employed by. <br />9. Attach a certified copy of a diploma or certificate of graduation from a schoot of massage therapy <br />including a minimucn of 600 haurs in saccess�liy campleted cou�se vs+ork as deseri�ed in Roseville <br />Ordinance 1 l6, massage Therapy Estabisshments. <br />10. Have you had ar�y previous massage therapist license that was revoked, suspended, or not renewed? <br />Yes Na l/ __ If yes explain in detail. <br />Licer�se fee is 75.00 <br />Make checics payable io City of Roseville <br />� <br />