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��s <br />Finance Department, License Division <br />2660 Civic Center Drive, RosevilIe, MN 55113 <br />(6S1) 490-2212 <br />Massage Therapist License <br />New License Renewal � <br />For License year ending June .�0 � � d�(1 <br />1. Lega� Name � l/� �i�,�_ ���-� .� <br />� <br />>. . . _ . : . . . / _ <br />Z. Home Address _ � <br />�. F3ome 'Telephone _ _ _-_ „_;� � � � <br />�' <br />� r ,{� � <br />4. BusinessAdd.ress 7 �a � ��L�t'1'� ��.. <Y. , �f�'-�- ��. �� ��1�� <br />5. Business Telephone � (�i � � � � � l — ! �� t/ <br />, ! <br />6. Date af Birth <br />_ � _ <br />-x n�--- _rr�:_.t.. <br />---a..—T ( V i D r L- <br />)f <br />� • <br />�,. , u.. Jv�a u�i v..i. �,iLiGCli: � �.., ��a� Y l <br />Naturalized? Yes No 7f yes, give date and place <br />{Attach a copy ofthe naiuralization papers) <br />9. Have you ever used or heen known by any name other t�an the legal name given in number 1 abo�e? <br />Yes No If yes, lisi each name along with daties and places where used. <br />10. Name and address of the ]icensed Massage Therapy Establishment that you expect to be employed by. <br />1 1. List all addresses at �+�hich you have ]ived d�ring the last ten years. (Begin with the mosf recer�t <br />