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���� -r <br />�� <br />I+inance Department, License Division <br />2660 Civic Center Drive, Roseville, IVIN 55113 <br />(651) 490-2212 <br />M�ssage Therapist License <br />New License <br />For License year ending June 30 <br />I . Legal Name ���� <br />� Home Addres� <br />Renewal <br />�� ���,��� �� <br />��� <br />���� � _ . , <br />/ <br />�. Home Telephone _ . . �, , � � � , • <br />�l�',P.� �� . �; '� ����._ ���� ����� <br />� Business Address ��� � ___, ,_, <br />� Business Telephone <br />i� Date of Birth— <br />,-. Place of Birth <br />� Are you an U,S. citizen? Yes <br />Naturalized? Yes <br />� ,.,, <br />_ No <br />_ No If yes, give date and place <br />(Attach a copy of tile naturalization papers) <br />9. H�ve you ever used or been ��: �;��.�� �>>�� any name other tlian the legal name given in number 1 above? <br />Yes 7+f� _ If yes, list each t�n�� along wit(i dates and places where used. <br />�T7�77e L.r,�l ��i�e. F'� I i�. e�.,d ;::.�M1��� Thera t bl s.hment �' ti•;��7 �x} e.�t a U� � n 1�}��d bw. <br />�:���� �����-� ����r .� � � ����.- ---- <br />:��`� �. 'N�� --.--.�� � <br />11. List all addresses at whicl� you have lived during the last ten years. (Begin with the most recent <br />