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2004_1206_Packet
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2004_1206_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 Licenseyear ending June 30 �. O U 5' <br />i <br />L. LegalName _����y��� �-- f�t,���, � <br />? _ Home Address <br />�. Home Telephone � .; ..�.-. f <br />4 <br />5 <br />l3,isin�ss Addresa�Cs� ����ti� ,��`I •�.��G <br />��� <br />Business Telephone <br />G. Date of Birth <br />-. Place of Birth . <br />�. Are you an U,S. citizen? Yes— _t��_ _ <br />Naturalized? Yes — ._No If yes, give date and place <br />(Attach a copy of the naturalization papers) <br />9. Have you ever used or been kn�•�n +��1 any name other than the legal name given in number 1 above? <br />Yes _ �'� . If yes, list each name along with dates and places where used. <br />10. Name and address of the licensed Massage Therapy Establishmentthat you e�ect to be employed by. <br />���ti <br />11. List all addresses at which you have lived during the last ten years. (Begin with the most recent <br />
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