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City of Rosevii1e, Minnesota <br />Application for Massage Therapist License <br />Please type or print in ink. <br />New License X Renewal <br />For license year ending dune 30, <br />1. Legal Name <br />2. Home Address <br />3. Home Telephone <br />4. Business Address _ <br />5, Business Telephone <br />6. Date of Birth <br />7. Place of Birth <br />8. Are you an US. citizen? Yes No <br />if <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 <br />a <br />number I above? Yes No If yes, list each name along with <br />dates and places where used. <br />l0. Name and address of the licensed Massage Therapy Establishment that you expect <br />to be employed by, <br />iv lot i r - <br />11— U e, <br />.4 <br />8 �D <br />