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� <br />� <br />� <br />Finance Department, License Division <br />2660 Civic Center Drive, Rosevllle, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />Ncw Li� �sr�w�' <br />For License year eridi l�rne 3� <br />l . Legal Name A �� _ <br />� � <br />�. Hart� Addrr�s . - <br />. } <br />! � � � . _. � � � <br />3. HamG Td'�atiarr� �� �� - -- — - — — <br />j r <br />� �- H7fslrr� A{idf� � � i � � 1 � �t� �� ll � rfM� I ���� � � �� �� I , '� <br />5- �va�r�'Celq�Li� �'�� � � �� �� x�� �� - - - — — _ -�--� <br />�i_ Date of Birth— � _ <br />— � -- -- <br />_ 7, Place of Birth �� . <br />� <br />�- Are you an U.S. citizen? YsB __�, No <br />Naturalized7 Yes No If yes, give date and place <br />(Attach a copy of the naturalization papers) <br />9. Have y�ou ever used or been ]mown hy any name other than the legal name given ui ttumber 1 above'? <br />Yes Np �� , If yes, list each name along with dates and places where used. <br />10. �n� and address of� I�ns�d � Therapy Establishmentthat you expect to be employed by. <br />.:r� �a� y �- <br />� <br />ll. List all addresses at which you have lived during the last ten years. (Begin with the most recent <br />