Laserfiche WebLink
� <br />New License <br />�� <br />� <br />�� �- <br />Finance Department, License Division <br />2660 Civic Center Drive, Roseville, MN 55113 <br />(651) 490-2212 <br />Massage Therapist License <br />Renewal <br />For License year ending June 30 <br />I . Lega1 Name ���+'��� �� � ����� � __ -- _-_ <br />� . <br />�. Home Address _ � <br />3. Home Telephone ,�, <br />�. �i�ssirass �4s�ross <br />�. Susiness T�L�; hpnG _ <br />�. Date of <br />---��.�r� <br />I <br />�� �� <br />���r1�,P _,���yl��� <br />�. Place of Birth ' ' <br />�3. Are you an U. S.citizen? Yes— No, _ _ <br />Naturalized? Yes ��. If yes, give date and place <br />(Attach a copy ofthe naturalizationpapers) <br />9. Have you ever used �r �e�n ]o�o+a�n �y any name other than the legal name given in number 1 above? <br />Yes � o „�, If yes, list each name along with dates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />� � r ` <br />-���� I��r�� ����'� ���r� <br />11. List all addresses at which you have lived during the last ten years. (Begin with the most recent <br />