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2004_0712_Packet
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2004_0712_Packet
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12/14/2009 1:43:03 PM
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��� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville,1�1�1 ��1�3 <br />(651) 490-2212 <br />Massage Therapist License <br />New License Renewal � <br />�or License year ending June 30 ��.� �� '�� <br />� � �— <br />L ���� Name � � �+ti r� s_� � "� � 1� K t �� _ _�� ' � . f +�' i � <br />�. Home Address <br />�. Horne Telephone k- __ — <br />�4 Business Address <br />�. Business Telephone �. .� ± — — <br />�. Date of Birth <br />' Place of Birth . . . . <br />�. Are you an U,S, citizen? Yes _ No <br />Naturalized? Yes 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 _ No If yes, list each name along with dates and places where used. <br />�-� <br />10. Name and address of the licensed Massage Therapy Establishment that you expect to be employed <br />��. ` ` j� _ <br />� "�;..:� �"....�� k��k;�� �.1 � f'k �: � �'- .�• . �. L� �� �� r� � <br />1 <br />�,.� i <br />� �� •}� A 1] ��}'� �� � � Y.��S�� t��' � � I�� � �51 i � "� <br />
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