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� <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />New License w ' Renewal <br />For License year ending June 30 <br />� <br />I , Lc�aa ��m� _��k� ���� � �� �' �. �� � <br />:., Home Address , , <br />3 Ho�ne Telephone ; ��-, . <br />��. Business Address <br />�. Business Telephone <br />�� Date of Birth — <br />�. Place of Birth - - <br />�. Are you an U.S.citizen? Yes No <br />N�t�iralized? Yes No <br />(Attach a copy of the naturalization papers) <br />� �_L� <br />If yes, give date and place <br />9. Have you ever used or been'-��.n�: ��� t-� R*�� name other than the legal name given in number 1 above? <br />Yes No _�fyes, list each name along with dates and places where used. <br />!�� ����rr. �r.tl ;a��l:4ss �t Iho i�r�as�ed �;�,s��rge 7�her��,� i��,�Jia�„�e,n� 1��,; Vu�i expec� 7�be �asipFuw� ;�w. <br />_, . <br />� t• I r--fi,F?''F� ��'� �{�i-_�Y�, i''}i "�. t y 7�7r1�`.�' } _ <br />-����G�•�5? �1�-�'- ��- -f�'S�c%�t �F�� ����- -.���i� — — -- <br />11. List all addresses at which you have lived during the last ten years. (Begin with the inost recent <br />