Laserfiche WebLink
CITY OF LITTLE CANADA <br />APPLICATION FOR MASSAGE THERAPIST LICENSE <br />Annual License Fee - $75,00 <br />New Application Renewal Application <br />Please compl.ete the following. <br />True Name <br />1i <br />LAST <br />FIRST FULL MIDDLE NAME <br />2. Residence Address / Cam. 0 % - <br />- i <br />3. Residence Telephone `' `" c' - 70 2 2 <br />q.. Business Address :;-? S'G `/ /'%,i ; cld (c. S..f.r- ci_c_-(- Z,'Y 7'" At: C.'.41, -cr.<< A., <br />5. Business Telephone c> 5/ - .„ 22 7 — 733 <br />6. Social Security Number <br />7. Driver's License Number <br />8. Date of Birth <br />9. Place of Birth C t% <br />10. U.S. Citizen? <br />Naturalized? <br />County <br />/ <br />Yes <br />Yes <br />/\ / c <br />City <br />i/ No <br />State <br />�- <br />No <br />If yes, give date and place <br />Attach a copy of the naturalization papers. <br />11. If you have ever used or been known by a name or names other than the true name given in <br />No. 1 above, list such names(s), and information concerning dates and places where used: <br />Names <br />Dates, Place, and Circumstances <br />s <br />9 <br />