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New License � <br />r <br />���� .. <br />��� <br />Finance Department, I.,����a�� Division <br />2660 Civic Center Drive, ���e�a��e�, �f� 55��� <br />�651) 4}4-2�12 <br />Massage Therapist License <br />Renew�t <br />� <br />For i.,ice�3s� year �r�ding June 30 � C• ��' � <br />l. Legal N��me �,�} �� �;`;�� �� �— ��'C� � •� L � ��_. ���lLF-+ <br />'�-. .'I �---- <br />2. Hpiz�� Address <br />3. I-lome Telephone _ _ <br />f�r � �;' <br />� �, ,�f ' � -' �,. { <br />'�. ��I�.'•1:7;:45 �5��{:IC1ti � � .� {'.�J i� �r +y � _ �I'�v i� � � _.�i <br />.. _. . ." " '_ '__ �" ' <br />�. �17�OIr�S� ;�::yl`�7�lC�l'K _��� [ � ti��.'r � � ' r' � [� �± • - <br />•- � <br />6. Date of Bitth <br />7. Place of Birth <br />0 <br />$. Are you ai� U.S, citizen'? Yes �� No <br />�I�ltui•��lizecl? Yes . No <br />(Attach a copy of the naturalization papers) <br />� <br />If yes, �ive d,lte and place <br />9. �-Iave you cverused or �een lu�o��rt�. by anyname otlier �tit�u ;i�.v legal �]07� giv�;il in nui��ber � above'? <br />'ti ���� No � If yes, list each n�m� aloi�� with dates rr,:; ��lzices where used. <br />i U_ �k �I �'1;`. :.fi{� ilt.�l'C�S k}C ;� � I��;J�:�;:G� � � 55iILV Ti °'� il�}�' I.'�Slil' � I: �'dl}I'.I' I;;1.41 �•�!sl � i}; �,;I "i}.�):: �;Il:�;�r �;t� i I'.'. <br />_�' f� r . <br />�i� � O��f,'_ t �L� �I •t�G't i� I t�.'F'��f �- tr�f � � .�-tf' <br />���� L�7� • — . �� . __ •-• <br />� <br />I l. List all addresses $1 which yo�have lived dtr�i�i� the last'�iti years. (Begin with the ii�astrecent <br />, <br />j. :[- i.-�;,' � 5. 4} �I <br />� <br />: <br />L_ <br />