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�����, � � � <br />� <br />Finance Department, �icense Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />New License ;�.�� Renewal <br />For License year ending June 30 � t' �� �t1 <br />4� I ''1r �y�� �� r� +� <br />1 . �:_�� ._ . �:.� it ,--L1 f��'�r ' �J4-�ti .�� f����N � . � � <br />_•� ' <br />---- � ri� yrl�'7,._ , i <br />2. Home Address _� - . _ <br />�" f�sa'�a •,: �' <br />3. �Toi��e Telephone :: �� - <br />4. Bttsines� Address ,� ����0 I:+�.� ��u�� � ��`i ��?- ��� _ OS �i t� i i�'C'/ , PI A� ��1 ! r� <br />5. BusinessTelephone ttJ��' ���_� �� �- ��'{' "�• <br />6. Dale of Birth <br />7. T'lace of Birth _. ��' r <br />� _ <br />8. Are you an U.S. citizen? Yes __ No <br />Natur�lized`? Yes No If yes, give date aild place <br />(Attach a copy of the naturalization papers) <br />9. Have you ever used or been known by any t�ai�ie other than the legal name given in nt�3nber 1 above? <br />Yes No �� If yes, list each ��me along with dales and places where ��sed. <br />10. Nai�Ze and address of the licensed Massage Therapy �sta�lisl�t�iet�t t���t you expect to be ei�7�aloyed 6y. <br />t+ •'��'�. �� �?� _S ���i-. � �1 <br />�_. �` �.uF._ ���a � a � �'� �� 1�� . ���� � �� � � � , �'� �� ��� <br />� <br />11, List all addresses at which you have lived during the last ten years. (Begin with the tnost recent <br />