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1 Ly, <br />- of Roseville, Minnesota <br />ppli at n for Ma a. Thera t License <br />Please type or pr�hit in ink., <br />New License Renewal <br />I " <br />For license year enidi,n,g June 30, ' ;- <br />, i I C rM <br />1 Legal Name <br />6. Date of'Birth <br />7. Place of Birth, <br />X-Ile 'Por <br />Are You an U'.S�. citizen? Yes No <br />Natu Tali zed? Yes 0 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 />number 1 ablovie? Yes I No V-I� If'yes, list each name along with <br />dates and places where used <br />10. Name and address of the licensed Massage Therapy Establishment that you expect <br />to, ble e�mpl,oyed by. <br />-At <br />K-) <br />