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� <br />Fi�a��ce Department, License Division <br />2660 CY�'ic Center Drive, RoseviYYe,1V11v 55113 <br />(651) 490-2212 <br />Massage Therap�st License <br />New License Renewal <br />For License year ending rune 30 �� ,..—. ___ <br />] . �.egeJ N�rne ,.. �` ^ _ . ��� _ � ��� <br />�. Home Address ~ � � � � � � '"r' � � <br />1 . <br />a . Home Telephone <br />�. Business Address � w� � Si�T�i���;fi,�=#�. A d � ��,��, f��� � <br />�. Business Telephone �„�'�,��' e���. _ _—_ <br />�. Date of Birth� , . <br />7- PlaceofBirth <br />�, Are you an CY,S. citizen? Ye6��Nq <br />Naturalized? Yes No __ If yes, give date and place � <br />(Attach a copy of the nah�ratizationpapers) <br />9. Have you ever used or been ion�o�wa by any nanze otlier tl�� the legal na�ne given in nurnbe,r 1 above? <br />Yes No If yes, list each name along with detes and places where used. <br />10. Name and address o�th� licensed Mass�ge Therapy�stablishment that you expect to be employed by. <br />� , -- �� <br />11. List all addresses at wl�ioh you have lived during tlze last ten years. (Begin with the most recent <br />