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•,� <br />k <br />r�� �''L � <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN SSll <br />(651) 490-2212 <br />Massage Therapist License <br />New License Renewal V` <br />For License year ending June 30 �,� ��� <br />i _ Le�] 1tiEme .����� � �.�.� .. ����.� �� <br />�, Home Address <br />,� � , . <br />i <br />.,.� <br />�._�� <br />�_ �arsic �f el�pfn�,� . _ , <br />�_ B�iba�c-ss �ddress ���I� ��r� �� � �� �' , <br />, ��� �Z.�.� E � ��r?` L.�� <br />�. E3�7�;naRS'F'�le���1�4 �L�� ����� ����! .—_ � — ----�– � <br />{�, Date of Birth _ �. <br />". Place of Birth <br />�. Are you an U. S. citizen? YeC i o <br />Naturalized? Yes No If yes, give date and place <br />(Attach a copy of the naturalization papers) <br />9. Ha�e you ever used or bee� ' any name other than the legal name given in nuniber 1 above? <br />Yes N� . If yes, list each name along with dates and places where used. <br />10. Name and address of the lic �se� rMas ��� ��t u expect to be cmpi ed ls�r� <br />� = =-r i [`�� � , —� � ����� . .�- � �� _ � �I� -��1��'—� �����- d�-� <br />F '�•� � � 4 � <br />� _ � I <br />4 <br />11, List all addresses at which you ha�e lived during the last ten years. (Begin with the most recent <br />� <br />