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CITY OF ROSEVILLE, MINNESOTA <br /> APPLICATIM FOR XASSA(;r5 THERAPIST LICENSE <br /> NE RENEWAL <br /> LICENSE FEE #* $75.00 <br /> Please Completz with typewriter or by printing in ink. <br /> Date q- �Y <br /> r <br /> 1 . True Name L 7 �..� _ � " l e <br /> LAST FIRST FULL MIDDLE NAME <br /> . r � <br /> 2. Residence Addres g ,71,/ <br /> 3. Residence Tele:lp on e 45-1 _ 49-3 <br /> - . <br /> 0. <br /> 4. Business Address <br /> 5. Business Telephone <br /> 6 . Place Of Birth 6 �� y <br /> COUN'T'Y CITY STATE <br /> . . <br /> 7. Date Of Birth .......................................................................................... .................................................................. .................................................. <br /> N /r).AY PrEAR <br /> 8 . U. S . Citizen? Yos No <br /> Naturalized? Ye s• No If -ves , give date and place <br /> .1 <br /> (Attach a copy of the naturalization papers) <br /> If you have ever used or been known by a name or names other <br /> than the true name given in No. 1 above, list such name (s) , <br /> and information concerning dates and places where used: <br /> 1james Dates . Place. and Circumstances <br /> Z T- 0 A) 11`74� A�A <br /> ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. <br /> ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. <br /> 1O . Name and address of the licensed Massage Therapy Establishment <br /> that you expect to be employed by. <br /> g.eve <br /> AS spna <br /> se,01 ES/13 <br />