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� <br />� <br />��� <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 <br />For License year ending June 30 <br />Renewal <br />�- <br />'. . I .C�: i i � ���11� _�Y��''' L� �',�'�' ?.• I .�• {�'• x �" ; - -- — <br />..�_ _ <br />�. Home Address <br />_ , .� <br />L_ I <�- <br />}� Home Telephone ��.���i �- � � .'�� �r�:����a;. <br />�_ I� �is i i7�ss ��d d; ess ,� �. .� tJh �' 4��� �� �,��ti�.4- �'t.i.s. �'r4� �r�,��'{'��; ���� ����3 i i -� <br />� �- <br />�. �'.� S�i1�s Tetie�hon� 1c �G 1 �' � 5 �M ' � � � � <br />.. Date of Birth- �_ti ,__ <br />'. Place of Birth <br />. � <br />, . <br />�� Are you an U.S. ��[�ten'r Yes <br />Naturalized? Yes <br />No <br />No If yes, give date and place <br />(Attach a copy of the naturalization papers) <br />9. Nave you ever used or been kii��u; n by any name other than the legal name given in nutnber 1 above? <br />Yes No If yes, list each name along with dates and places where used, <br />1�, I'+��� i i'.�: �tn�! a�id r�s� �f kl i� :S��flaf+� �lL�tiS i9 C� I7 rrap� F sk��l i5h:n v nt �ha� ;�a�i cxnc�t io I�c e ��, �; Ik�,�c;� �: y�, <br />� w � '���{4��3 ��7�ti' {��-. � _ �-4�M�' �� �Jti4'5����'�r1�7�'1��� 4��1� -`�rr��� <br />a � <br />_ -• �� . <br />11. List all addresses at which you have lived during the last ten years. (Begin with the most recent <br />�� <br />