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� � �L <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />, <br />New License '� Renewal <br />For License year ending June 30 ,�L• �•�� <br />ti- <br />I • �.e�i71 �lE��nG �� �' � �'w,�'r- �-�r �' •- �. <br />� Home Address _ � <br />, <br />3 Home Telephone <br />�. L3usi��ss Addr�ss ° !�- -;' �.•� �' �' �� f{ �� <br />+�= �----� — - - <br />�, Business Telephone <br />b Date of Birth <br />-. Place of Birth <br />� Are you an U.S, citizen? Yes No� <br />Naturalized? Yes No If yes, give date and place <br />(Attach a copy of the naturalizationpapers) <br />9. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes No If yes, list each name along with dates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />11. List all addresses at which you have lived during the last ten years. (Begin with the most recent <br />