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<br />, <br /> <br />CITY OF ~ITTLE CANADA <br />APPLICATION FOR MASSAGE THERAl'IST L1CENSE <br />(Mu~t be accesSory or incidental to properly zo~ed beauty salon.) <br /> <br />Lioense Fee - $75.00 <br /> <br />NEW <br /> <br />___ RENJ;;WAL <br /> <br />Please oomplete the ~ollowing. <br /> <br />i. True Name <br />MS'l' <br />2. Residence A~aress_____ <br /> <br />J. Residence Telephone____ <br /> <br />FIRST <br /> <br />FULL MI)DLE NAME <br /> <br />4. Business Address <br /> <br />5. Business Telephone~ <br />6. S,)cial Security Number_. <br />? Oriver's License Number <br /> <br />---.-..--- <br /> <br />8. Date of airth <br /> <br />'-.---- <br />Mo./Day/Year <br /> <br />9. Pl~ce of Birth____ <br />County <br /> <br />-.- <br />City <br /> <br />-sta.te -- <br /> <br />10. O.S. Citi~.n? <br />Na tura lJ. zecl? <br /> <br />'fes <br />Yes <br /> <br />-- <br /> <br />No <br />No <br /> <br />If Yes, give date and place <br />Att~ch a oopy of the naturalization papers. <br /> <br />11. If you have ever used or been known by a natte or names other <br />than th~ tru.e. name given in No~ 1 abc.ve, list such nal'i'H~(s), <br />and information concerning elates and places where used, <br /> <br />Names <br /> <br />Dates. Place. and circumst~ <br /> <br />-~--- <br /> <br />12. <br /> <br />N~me and address of the licensed Massage Therapy <br />Establishment that you expect to be employed by. <br />accessory or incidental to properly ~oned beauty <br /> <br />(Must be <br />salon. ) <br /> <br />--- <br /> <br />--- <br /> <br />~n '~ <br /> <br />q"Gbl?Qu rea 'Ii'-l Ifl-l..! <br /> <br />I-1r"H..a..1J..1I'l ':11/ i r 1 J() J 11'1 <br /> <br />C:;'hT t..lnn IJ1_C"_l1J.JU <br />