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��� <br />��K <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />New License �.f <br />Massage Therapist License <br />Renewal <br />For License year ending June 30 `LS� �.� <br />1 <br />2 <br />a <br />Legal Name �� � �'��€.� y�_�� `=1 <br />Home Address � �.. <br />� �r4�� <br />t{u«i� T'�Se�l:une ��.,.� <br />� 4 <br />�, �USif�C,i•.£ ��C�SS -��r•�+�.��`- L-{����+ �1�5;.��� ._.�,�i�'.� }f+�.��,�"�ti�� ���'� <br />1, °�tiS:iti�� T'c:r�h�no <br />6. Date of Birth <br />7 <br />� <br />Place of Birth <br />� �� � ti � � � f' <br />Are you an U.S.citizen? Yes, <br />Naturalized? Yes <br />� �.. k'����-� - -' ' - - <br />No <br />No If yes, give date and place <br />(Attach a copy of the naturalization papers) <br />9. Ha�e 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 na�ne along with dates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />— — � <br />�.i_;; {�,��.� �,��.�i� c,�i i�����?'�,� (�G�� •]�-�,� �� , �'�,���a�,; ti� -��� �,��,��� <br />t <br />11. List all addresses at which you h�ti�� lived during the last ten years. (Begin with the most recent <br />