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��� �L� « n�R�r�ti�i�� <br />� <br />� <br />New License <br />�z`lY4tlff*I�� <br />� F7� <br />�r� 1 z - <br />Finance Department, License Division <br />2660 Civic Cez�ter Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />Renewal <br />For License year ending June 30 � od`� <br />I Legal Name ���. l� /'e/� 1�� ,� f,r� t� _ _ <br />�. HomeAddress _ —r-- ._,_ __� <br />�� <br />.� Home Telephone _ _ _T — � � <br />� <br />'. Business Address C� �} .� � ���, �� ����� � <br />� Business Telept�one ��� � � j <br />. , , � <br />+s. Date of Birth_ � <br />� � <br />' Place of Birth _ � <br />x• Arc you an U,S. citizen? Yes No ! <br />Naturalized? Yes No If yes, give date and ptaee I <br />i _ ._ <br />(Attach a copy of the naturalization papers) i <br />9� Have you evcr used or been known by any name other than the legal nitt�e given in numb Ir 1 above? <br />Yes _ No If yes, list e2ch name along with dates and places ;��: � used. <br />1 <br />_ 1 <br />' � '• � -. --h—• -- <br />--• �,1 �- •-- <br />I�, ��i�e nd 7d� rrss �f i:�c I ie�ry� d�;ass�g� TI:: rp�y Establislunent chat you expect to be t�n��l�}x� by. <br />�1 (1��? *.� —t I�I�I,�� ��J.h�1��Jf � <br />I: List all addresses at which you have lived during ti�e last ten years. <br />t �' � � �• ��-�--? � �_ • �- ��� , ��.��k�� <br />� �� �G�� � ��� <br />� �� � ��� ��� � ��� �t�� <br />-- � _. , .�,�, <br />I <br />_' '_'�,_�_ <br />(Begin with the mos� reccnt <br />