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2004_1025_Packet
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2004_1025_Packet
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Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />New License � Renewal <br />For License year ending June 30 <br />1. Legal Name ��� ��� �t �� � � �� <br />� <br />� _ - �ti � <br />2. Home Address <br />3. Home Telephone _ <br />4. BUSmeSS AddYeSS <br />� � - - <br />Y�� � ._ � i � ■ #� , ■ r i <br />. ��• <br />5. Business Telephone ��� � � � � �� � +� � �, <br />6. Date of Birth <br />0 <br />7. Place of Birth <br />8. Are you an U.S. citizen? Yes— �__'o, <br />Naturalized? Yes No <br />(Attach a copy of the naturalization papers) <br />� — � _. <br />If yes, give date and place <br />9. Have you ever used or been 4mg�rr by any name other than the legal name given in number 1 above? <br />Yes N� �* tf yes, list each name along with dates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishmentthat you expect to be employed by. <br />11. List all addresses at which you have livedduringthe lastten years. (Begin with the most recent <br />�. <br />a <br />� <br />
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