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��� '� <br />�� � �--�. <br />�+'inance Department, License Division <br />2660 Civic Center Drive, Roseville, VIN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />. . .. .,. , _,_ _ <br />New License }'L Renewal <br />For License year ending June 30 <br />. y „ , ,_ <br />. �, . . � r L <br />�. �'�'�L� �1�IL' ��� LA_ , � � . -,� 7 � I • � 1 ��� 4 ;1 y 5 <br />�. �'��115� r���l'�R� • •— <br />'� Home Telephone � ti a <br />ti i ' , i I' �. 45 �4 �y � <br />4. Lx��� �� I� SS �C�{�T��S ~ �; � r � � � � t. �f • } � r� �_� _• I - j � I i �� ,', � 1 . � . �'-� �� � � � � � `• <br />{. Business Telephone _ <br />,= <br />�:i. Date of Birth. • ' {' = 7 <br />. Place of Birlli , f •,. <br />� <br />;� Are you an U.S. citizen? Yes No <br />Naturalized? Yes No Ifyes, give date atid place <br />(Attach a copy of the naturalization papers) <br />>. Have ynii ever used or bee .�"1��V� ly by any natne other tlian tlle legal n�m� given in number 1 above? <br />Yes T`� �_ _ If yes, list each na11�e along with dates aild places where used. <br />10. Name and address of :;i{: I i�;;; i��v�! Massage Therapy Establishment that you cx�c�.l ku U�. �ir, ; u��°d �: � <br />�'�.L��•,�'.�:�� �. �:'� . � �M:. `1.-`I�'�' y i� �It r' � ti � C_ � �; �; ? i'° 5 I � 4 <br />1 ti � . i�� :.� : � � <br />��� � f � I <br />.k �' •.�' z �'ti : � I•.:, i ti � f . a <br />11. List all addresses at -,ti�i;�.17 you have lived during the last ten years. (Begin with the most recent <br />