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<br />CITY OF LITTLE CANADA <br />Al'PLICATION FOR MASSAGE THERAPIST LICENSE <br />(MUst De accessory or incidental to properly zoned beauty salon.) <br /> <br />License Fee - $75.00 <br /> <br />NEW <br /> <br />RENEWAL <br /> <br />Please complete the following. <br /> <br />1- True Name <br /> LAST <br />2. Residence Address <br />J. Residence Telephone <br />4. Business ACldress <br />5. BUsiness Telephons---,- <br />6. Social Security Number <br />7. Driver's License Number <br /> <br />PIRST <br /> <br />FULL MIDDLE NAME <br /> <br />B. Date of Birth <br /> <br />- <br />Mo./Day/Year <br /> <br />9. Place of airth <br />County <br /> <br />10. U.s. Citigen? <br />Natura li zed7 <br /> <br />Yes <br />Yes <br /> <br />City <br /> <br />No <br />No <br /> <br />state <br /> <br />If Yes, give date and place <br />Attach a oopy of the naturalization papers. <br /> <br />11. If yeu have ever used or been known by a name or names other <br />than t.he true name given in No.1 above, list suoh name(a), <br />and information ooncerning dates and places where used, <br /> <br />Names <br /> <br />Dates, Place, and Circumstances <br /> <br />12. <br /> <br />Name and address of the licensed Massage Therapy <br />Establishment that you expect to be employed DY. <br />accessory or incidental to properly zoned beauty <br /> <br />(Must be <br />salon. ) <br /> <br />Fn ''; <br /> <br />P,Gf1I7PbIGQ 'nlJ VIi.l <br /> <br />IinlilJl.J~ "11111 .In 111~ <br /> <br />C;',bl IJnll In-07-11Hll <br />