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2004_1108_Packet
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2004_1108_Packet
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�L� r r �� k�*�M <br />� <br />Finance Department, License I3���� <br />2660 Civic Center Drive, Rosevitle, N.CN ��11� <br />(651) 490-2212 <br />MASSage Thexap�st License <br />New License Renewal L ��� <br />For License year ending June 30 <br />1 _ [: eg,a] .�I�ne � ,�-�� _ �r���'7 � 7 ���f .�� ,�1•��� _,.— <br />n <br />2. Home Address , � <br />' ' �.. � . <br />3. Home Telephone � i _ <br />4. Business Address <br />5. �v+int�si�3ap�me ��6!���. � ,�� � � � � � . — - <br />�- <br />6. Date of �iui� <br />r • .-, <br />7. �'�ace of Birth <br />,�� �% � ' � � <br />8. Are you an U.S, citizen? Yes, <br />Naturalized? ��+ �� , , . �„�,,, .. � �a, give date and p�ace . <br />(Attach a copy o fthe ���:�I ;xa'��� papers) <br />9. Hs.ve you �ufr used or bQem kcaowz�; by �1y �13T.1e other than the legal naqq� given in t�untl�er 1 above? <br />Yes �_ No - If yes, list each name along with dates � places whexe used. <br />� <br />� '" r <br />�� <br />10. Name arid address of the �iceztsed MassageThernpy Establisl�tnant that you expectto be employed by. <br />���'��_. � ��� � fi, ��� ..., � ��� -- �������� � ��� �� ��� �� � � � � <br />� <br />11. List all addresses at whicb you ktave �ived during the last ten ye�s. (F3egi.ci with �� �ost recent <br />� <br />� <br />' ��� . , - •- � � <br />
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