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<br />. <br /> <br />CITY OF LITTLE CANADA <br />APPLICATION FOR MASSAGE THERAPIST LICENSE <br />(Must be accessory or incidental to properly zoned beauty salon.) <br /> <br />Lioense Fee - $75.00 <br /> <br />NEW <br /> <br />__ RENEWAL <br /> <br />Please complete the following. <br /> <br />1 . True Name <br />LMT <br />2. Residence A~aress <br /> <br />l'IRST <br /> <br />FULL MIDDLE NAME <br /> <br />... -------- <br /> <br />3. Residence Telephone_____ <br /> <br />4. Business Address <br /> <br />5. Business Telephone <br />6. Social Security Number_. <br /> <br />7. Driver's License Number_________._.__ <br /> <br />8. Oat. of Birth___ <br />Mo./Day/Year <br /> <br />9. Pl~ce of 6irth____ <br />County <br /> <br />City <br /> <br />----- <br />Stat.. <br /> <br />10. U.S. Citisen? <br />Naturalized? <br /> <br />Yes <br />Yes <br /> <br />No <br />No <br /> <br />If yes, give date and place <br />Attach a copy of the naturalization papers. <br /> <br />11. If you have ever used or besn known by a name or names othBr <br />than the true name qiven in No.1 above, list such nama(s), <br />a!1d information ooncerning Clat~s and places where Used, <br /> <br />Names <br /> <br />Oates, Place, and Circumstances <br /> <br />--..- <br /> <br />12~ <br /> <br />Name and address of the liCensed Massage Therapy <br />Establishment that you expect to be employed by. <br />accessory or incidental to properlY zoned beauty <br /> <br />(Must be <br />salon. ) <br /> <br />L_ __ <br /> <br />~n '~ <br /> <br />Q~GhhOb!C(\ '1\1.\ VI-l, <br /> <br />~nl-l~l-l~ ~'j 11' JI\ 11 I~ <br /> <br />C;' I hT un:.! TI"_C'_1JI-lU <br />