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N�ew License <br />Massage Therapist License <br />Renewal <br />For Licensc year ending JUne 30 _���� <br />L Legal Name <br />2. Hoiinic Addr�es <br />6. Date ofBirth.- <br />7'. Place of Birth, I 1 1, <br />s. <br />8. Are you an U.S. ci,tizell? yes —No <br />Natut-tifized? Yes No If yes, give date and place <br />(Attach 4-1 copy ofthe naturalizatioll PaPeLOi j <br />19., I-lave you ever used or been Icnown by a ny name, oflier than the legal name give ii in number I above? <br />Yes No if yes, list each rear ilef"long with dates -rand places where used. <br />10. Nriine are daddL-c�ssoftlic licellsedM.-,issaneTtierap stcibi,istitnetit that )toiucxp ttolie e�iilplloyedby. <br />f 2. <br />11. List all addresses at whicl, you, have lix-red during the last tell Years. (BegiiiiAit,,Ii the i-nostreceilt i. <br />