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2004_0712_Packet
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2004_0712_Packet
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r <br />�� � <br />� �`' <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, I�1C�! 55:��� <br />(651) 490-2212 <br />Massage Therapist L������ <br />New License — Renewal � <br />Por License year ending June 30 ._��� <br />- -� • r f� <br />I 1_c�;f: N,i�77c ,: I'-�•wii•� F���'; � ..— — <br />). Home Address � <br />�. Home Telephone <br />�' . Business Address <br />a �_ <br />�. Business Telephone _ ' � <br />��. Uate of Birth- <br />� <br />-. Place of Birth <br />�. Are you an U. S. citizen? Yes i'.. No <br />Naluralizeci? Yes No <br />— 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 '�r No If yes, list each name along with dates and places where used. <br />. <br />M ' - -` <br />10. Name and address of the licensed Massage Therapy Establishment that you expect to be employed <br />�i� 5' . <br />. 'r I -T <br />• � I <br />
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