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�.i./ �JLL <br /> Finance Department, License Division <br /> 2660 Civic Center Drive, Roseviffe, MN 55113 <br /> (651) 490-2212 <br /> Massage Therapist License <br /> New License R Renewal <br /> For License year ending June 30 <br /> 1 Legal Name <br /> 2 Home Address <br /> 3 Home Telephone _ <br /> 4 Business Address �� U�� l� ���t`� c�� . `-('+`1 �� C`'C.t.(�Q fl�/L.` fiSq-3 7 <br /> 5 Business Telephone _�l S�. ( 1 S�.—�1 U�• <br /> 6 Date of Birth <br /> 1 Place of Birth <br /> 8 Are you an U.S. citizen? Yes _No <br /> Naturalized? Yes No If yes, give date and place <br /> (Attach a copy of the naturalization papers) <br /> 9 Have you ever used or been known by any name other than the legal name given in number 1 above? <br /> Yes No If X list each name along with dates and places where used. <br /> 10 Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br /> t2 L2 L <br /> sa)& ( <br /> 5-571s <br /> 11 List all addresses at which you have lived during the last ten years. (Begin with the most recent <br />