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r apist <br />Vlassage Ther Licens,; <br />New License Renewal <br />For License year ending June 30 c-,Q &0,.3 <br />1, Legal Name ' " .-. Sks u <br />2. Home Ad&ess <br />3. Herne Telephone IF <br />4. iu <br />Business Address <br />5. Business Telephone <br />6. Date of Birth <br />7. Place of Birth I A ; .. _ <br />8. Are you an U.S. el tizen? yes No <br />Naturalized? Yes No if yes, give date mid R lace <br />(Attach it copy of the naturalization papers) <br />9. Have you ever used or been known by any nar"le other than the legal name given ire number 1 above? <br />'es � eve . <br />No If yes, list each name along with dates and places where used. <br />10. Name and address � of the licensed Massage Tljerapy Estahl ishment that you expect to he employed <br />y � by. <br />r <br />I O.r% VI IL Ave. <br />z <br />y <br />11. Last alI addresses at which you have lived during the last ten years. (Begin with die most recent <br />