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2004_0712_Packet
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2004_0712_Packet
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�4� � � <br />�I <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />New License <br />Renewal <br />k��r ��c�*�s� ��cz�e ci7d ing ��iqe ?0 .� ���� �� <br />,C. f f .� <br />Lc�l NA[Ile i, . i' i �: •` l��.-.'i. r'i F'.• � i �• �'� � �i � �+��� � ���'�. � = ��1;��� _t'.r � <br />1 1 1 Tlii�l�� T' V <br />J/ . - <br />�. Hr��7c �.dd*�s� � -- <br />�. IIun�e Te.h:p!«n� . „ + <br />��� � <br />�, R,_sine-s� Address r•��a�'��� ��?. �.r��'���.��� �'i�=#�} � . �, �� � ���f � <br />S. ��isEr��sS T�L��}�onc ���_� �`� �'� -- ������� — <br />6. Date of Birth- <br />7, <br />E� <br />Place of Birth� <br />Are you an U.S. citizen? Yes— <br />Nah�ralized? Yes <br />_ No— <br />_ No - If yes, give date and place <br />(Attach a copy of the naturalization papers) <br />r� � <br />9. Have you ever itsed or �t°'"°•��^ �•- °"�� name other than the legal name given in number 1 above'? <br />Yes N� _ ,�, list each r.nm� along with dates and places where used. <br />10. Nan1e and }address o ��{I �e licensed Ma�s�ge Therapy Establishment that you expect to be employed by. <br />�'�.fXl r? i.'F f7 �.. � � 1 J �a ��� f f � � �f .��R' ! � <br />``�� ` ��f ��•�—����-��������r"�� � � ������ <br />11. List all addresses �C which you have lived during the last ten years. �F� �.�ii, with the most recent <br />
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