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�- �� '� <br />.��� w. <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 I,icense year ending June 30 <br />� l-=€'�' I � 7;77c _ �' �� �,; t'��'� ��i�+, �, �� ��� <br />L <br />� . I-Iome Address — _r, _� �_ ._ , - -- -..r.�� ... . . `. . ' .. , . , <br />� <br />. . Home Telephone _ <br />- Business Address <br />. Business Telephone <br />L:. Date of Birth— _ . . .. . <br />', Place of Birth ____—_ _ _ ", , _ _ _ <br />,ti Are you an U.S. citizen? Yes_�� No <br />Naturalized? Yes _��_ _ If yes, give date and place <br />(Attacli a copy of the naturalization papers) <br />9. Have you ever used or been known by any natne other than the legal name given in nulnber 1 above? <br />Yes No _ If yes, list each name along with dates and places where used. <br />�—_ <br />10. Name a�id address of the licensed Massage Therapy Establishment that you expect to be employed by. <br />� <br />. � ���y��' .���.���t �. <br />11. List all addresses at which you have lived during the last ten years. (Begin with the t�.ost recent <br />