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CITY OF LITTLE CANATJA <br />APPLICATION FOI2 MASSAGE TIIERAPIS'T LICENSE <br />Annual License Fee - $75.00 <br />J~_ _ New Application <br />Please complete the following. <br />1. True Name . ~CJ~ (~~ l~~al ~ e~,~~ ~ <br />2. <br />3. <br />4. <br />5. <br />6. <br />7. <br />x. <br />9 <br />10. <br />11 <br />Renewal Application <br />~~ 11 <br />LAST `FIRS"f FULL MIDDLE NAME <br />~ ~ 7 -s ~, <br />Residence Address ~-'~ ~~ ~' l ~C6 ~ ~~ ~~~~~ ~<?. ~~"=~, ~c"'~- M n <br />c- -. <br />Residence 'T'elephone ~~ • ~ I ~ ' ~ ` ~ ~'' ~~ <br />Business Address <br />Business Telephone _ <br />Social Securi: <br />Driver's Lieen <br />Date of Birth _ _ <br />Mo./Day/Year <br />Place of Birth Z` "~"~-- ~ ~.~ `t'.(~' %c'.~<' '~-1 __ <br />County City State <br />U.S. Citizen? ~ Yes No <br />Naturalized? Yes ~ No <br />Tf yes, give date and place <br />Attach a copy of the naturalization papers. <br />If you have ever used or been known by a name or names other than the true name given in <br />No. I above, list such names(s), and information concerning dates and places where used: <br />Names Dates, Place, and Circumstances <br />A <br />2 <br />