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2004_0712_Packet
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2004_0712_Packet
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�� <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />New License �cG�cwa] � <br />ti <br />For License year ending June 30 _�'�3�� <br />; <br />�. �.��.Zi r�e� <br />�1����1 �� , ��-���� <br />f ��ome Address <br />�_ Home Telephone •...._ R-,�� - <br />..._, . --- <br />�. Business Address <br />5. Business Telephone _ <br />� � , - <br />��. Date of Birth . ., V <br />f7 <br />1 Place of Birth � <br />� Are you an U.S. citizen? Yes <br />Naturalized? Yes <br />� <br />No <br />No If yes, give date and place <br />(Attach a copy of the naturalization papers) <br />9. Have you ever used or been known by any name other than the legal name given in number 1 above? <br />Yes <br />Na 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 <br />�� r�� ��.��_� _- <br />I <br />
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