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��4.1� '�' _1 <br />�r�...� , _ _ �_ 1 � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />r <br />New License Renewal � � <br />For License year ending June 30 <br />I. Legal Name .��. '�'' �;:'' j�� i���r�.�� <br />� <br />2. Home Address <br />- - �� <br />�. Homfi T���4F�1}7v �� <br />vK� •X • � ' ��I — �' fi i C��� �,,� �{,'t���l � �r�rd� <br />�1. U�:s�:�. ti , �.:,�ti:�, : �.�� � � .� _� �� �� s� t I� <br />�, Business Telephone L'�� � ~��' � � '~ 1•� � � � , <br />5. Date of B <br />7. Place af Birth _ _ _ _ <br />8. Are you an U,S. citizen? Yes No — <br />Naturalized? Yes _ —'-`��— <br />(Attach a copy of the naturalization papers) <br />�� - <br />— If yes, give date and place <br />9, Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yz{ No _ If; es, list each ?��me al�n� with dates a.nd places w� w�e used <br />10. Name and address �. f' I i�' .= <br />_� �� � �'_;; , ��d .i . i <br />F <br />..r.�. �.�.� �� � <br />� l�:�ss;:�= ���tr�pti� Establishment that you expect to be employed by <br />�f� 4 �i l ['� <br />- —. <br />'�? , _ . r ? <br />..- ��'f _� <br />1�. List all addresses at which you have lived during the last ten years. (Begirt with the most recent <br />