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{ <br />ti <br />r <br />Finance Department, License Divisiaxl <br />2660 Civic Center Drive, Roseville, MN 5511 . <br />(651) 490-2212 <br />{ <br />..ti <br />IR <br />Massage Therapist License <br />New License Renewal <br />For LiceIYse yep r ending Rine 30 <br />r <br />I. Legal Ninie / i l l <br />2. Rorie Address <br />3. Hotne Teleph -; <br />4. Business Address � Ll C� <br />5. Business Teletiholie ����_ �•� ��� - � -�t~� _��":� <br />6. Date of Biral .� <br />7. Place of Birfl- t � . L 1. - , L , 1, <br />Are you an U. S. citizen � . Naturalized? es i date � <br />� give and g place <br />(Attach a copy of the naturalization papers) <br />9. Have yeti ever use or been ljle n by my name other than the le aI nam iven i <br />Yes g n number i above? <br />No If yes, list each name along with dates and places where used. <br />10* -crane and address of the licensed Massage Thiel -apy Establishment that t ect ou e� <br />}� o be enzpleyed hy. <br />III.II. <br />I 1. Dist all addresses at which you have lived during the Iast ten . ears w, <br />�' (Begin i tlj the most recent <br />