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� <br />New License <br />�� <br />���� � <br />Finance Department, License Division <br />2660 Civic Center Drive, Rosevi�le, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />Renewal <br />For License year ending June 30 <br />1, I c1�,�� �C;�in� ���.� �1 . �.. ������ <br />2. Home Address � <br />3. Home Telephone <br />4. Business Address <br />5. Business Telephone <br />6. Date of Birth- <br />7. Place of �ir�i� <br />5 /�75,��-���� <br />8. Are you an U,S. citizen? Yes _ No <br />Naturalized? Yes No <br />(Attach a copy of "i7t' naturalization papers) <br />If yes, give date and place <br />9. Have you ever used or been lcnown by any name other than the legal name given in number 1 above? <br />�4� _ 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 />��� {--'f ��?�3� — ���J� �� /�d�'��� I��� <br />11. List all addresses at which you have lived during the fast ten years. (Begin with the most recent <br />._ A . a i faV i_ <br />