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New License <br />�� <br />��r <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />Renewal !� <br />For License year ending June 30 r�s�o� <br />� �.y�� <br />� . ��ai t���,� _� . , <br />. s . ^_� <br />, <br />�. Home Address � � - ..-.... � s:�� :°.i a ' . ` ' - "" � <br />� � �a � <br />3. Home Telephone .. <br />4 ti � <br />�, BusinessAddress _ - <br />�, BusinessTelephone �1 �ln7il - �'�� <br />fr_ Date of Birth + , ., � <br />�. Place of Birth <br />$. Are you an U.S.citizen? Yes No <br />Naturalized? Yes No If yes, give date and place <br />(Attach a copy of the naturalization papers) <br />9. Have you ever used or been �own by any name other than the legal name given in number 1 above? <br />Yes No If yes, list each name along with dates and places where used. <br />10. Name and address of the licensed Massa e Therapy Establishment il� ��uC,� �� I,c} �e �:n- L���ed �y. <br />_ ti i� . �Ti,.�v�n : , � ��'1 rO 3,�1 iG� �: m�rt�t _� .,r} �4-3 ���5.�� �So i1�46�� �,f.14 � <br />11. List all addresses at which you have lived during the last ten years. (Begin with the most recent <br />. �.,�. <br />_ ., <br />U <br />