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�� � <br />�-,�.✓ <br />rinance Deparhnent, License Division <br />26G0 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist Li�cense <br />(�.Y�New.License �„� Renewal � � <br />.. ,�-:� <br />For License year ending June 30 �� ��r � <br />1. L.egalName �f.��/£ �E��/)� D�/19 �� � ,�.;_T- <br />�; �i,� .-, � � <br />2. �o�rne Address � , <br />r <br />3. ��e Telephone <br />4. Business Address <br />5. Biisiness Telepha <br />r <br />6. ll�te of Birth . <br />7. Place of $irCd� <br />� <br />8. Ai�e you an U.S. citizen? Yes No <br />Nuturalized? Yes No If yes, give date and ptace <br />(Attach a copy of tl�e i�a,turalization papers} <br />9. Have you ever used or been known by any name other than the legal name given in m�mber 1 above? <br />Yes No If yes, list each naine along with dates and places where used. <br />; . �. ,. , - � ,� <br />..� . .r . 'J . <br />\ � •� •-- •-••� . � ./''y :i <br />•j J���„ j <br />l0. Name and �claress or cne ucenseu �v1a�s�Ke � nerapy rstfln�isnment that you expect to be-empie��e�-iiy. <br />.. - •, <br />11. List all addresses at which you h�ve lived during the last ten yeais. (Begin with the most recent <br />