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2004_1108_Packet
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2004_1108_Packet
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. ��� <br />�� <br />�, 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 />.. L.vg�L ?i �:ri�. � f'l. i�.#� �,1j *� � �x�� <br />� <br />2. Home Address � ' - � , , v � - • � ' - �• � - <br />,� <br />?. Home Telephone _ <br />'• �i'•_SI:IeSS�{]l�fCSS� � �� ��-�l.���� ��t��(�, 1 ���_�u,r�'4� ��L`, ���r��r+��.�' 7 <br />- � `�� , � <br />�. Business Telephone. �� �� � �' � �� � �' � � �� � '� � � � � <br />• �, :� _ <br />+� . Date of Birth � <br />'�, Place of Birth _ � -, � - • � � , . <br />8� Are you an U. S. citizen? Yes — �„ �,. <br />Naturalized? Yes .,,.__,�_,�___ .. yes, give date and place <br />(Attach a copy of the naturalization papers) <br />9. Have you ever used or been k?��+�rr� by any name other than the legal name given in number 1 above? <br />Yes No _"" Ifyes, list each name along with dates and places where used. <br />! 0. �'�m� and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />_ � �4 �� ��-�*� �� �: <br />{ `� �� �.�. �#u�k�� ��_��� ������ ������� <br />1 L List all addresses at which you have lived during the last ten years. (Begin with the most recent <br />
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