Laserfiche WebLink
kam&C <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490 -2212 <br />Massage Therapist License <br />New License \ Renewal <br />For License year ending June 30 ` <br />1. Legal Name <br />2. Home Address <br />3. Home Telephone r v.� , <br />4. Business Address Cad') CU <br />0 <br />by-ku �. <br />Business Telephone U ( — ..7 3G - L� COO <br />0 <br />6. Date of Birth <br />7. Place of Birth <br />8. Are you an U.S. citizen? Yes ;;v <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 yes, list each name along with dates and places where used. <br />ltrIt <br />n <br />4 "I 1 -3) <br />10. Name and address of the licensed Massage Therapy <br />_- -I 1 % t\/ <br />that you expect to be employed by. <br />M 00 C-0 c'c j' Rick l2 - _t k-c' 1/-) !n X 113 <br />11. List all addresses at which you have lived during the last ten years. (Begin with the most recent <br />