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� <br />��� � <br />���� - --- � � � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License � <br />� a <br />New License � , ' Renewal <br />For License year ending Jui�e 30 �� ��r� �� <br />� f '' i <br />1. Legal Name - �- -:�� �'�-��.l..f�� _. � � ��"r; .%�i:% <br />2. Home Acldress _ <br />3. Z Iome TelephonP <br />4. Business Address <br />5. ]3usiness Telephone <br />1 <br />6. �Date of I3ii-th <br />7. Place of Bii-th <br />,• <br />� <br />4 <br />, <br />S. Are y�u e.n U.S. citizen? Yes— . No � <br />Natur�,lized? Yes __�� _ 1�� If yes, give date and place <br />(Attach a copy of the naturalization papers) � <br />�, <br />�r � ! <br />� <br />9. Have you ever used or been known by any name other than the legal ^ a�-.� given in number 1 above? <br />Yes If yes, list each name along with dates and places where used. <br />No � <br />1�. Nair_c �nd ��fr=s :�i�il��c licensed Massag� T��rapy Establishment that you expect to be employed by. <br />- -- f ����.' ��� ���� �� -� - �r ���� <br />� <br />I � <br />11. List all addresses at which you have lived during the last ten years. (Begin w�th the most recent <br />. ,.Q <br />r, �; <br />�' � ' f t� r _. . <br />� � <br />-. , � � � rr _ .r _ s �� <br />� "- Y � ' - <br />f <br />_� <br />� <br />- � +�_r. .. <br />� � } <br />