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CITY OF LITTLE CANADA <br />APPLICATION FOR MASSAGE THERAPIST LICENSE <br />Annual License Fee - S75.00 <br />New Application <br />Please complete the following. <br />l . True Name f' t ; i '� t) ! <(. ('L 1161 <br />Renewal Application <br />FIRST T FULL MIDDLE NAME <br />2. Residence Address d o 4, /7 /4/ /3(-41," / e 4.?d 'V4,,1 vhq ye v. <br />3. // <br />4. Business Address l �'t/ M77 <br />5. Business Telephone ())121-, 718 n_t tOx (.1' / „ )6'7 -11.V <br />6. Social Security Number _ <br />7. Driver's License Number <br />8. Date of Birth. <br />Residence Telephone 41 ) op 14Z, <br />Mo.. Day ear <br />9. Place of Birth 6774.g a„ X1071 - <br />County City <br />10. U.S. Citizen? Yes '/ No G ?'L'Gti <br />Naturalized? Yes No J <br />State <br />CA/N1 — 2 7Y • <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 />'' 71 01,(',16 <br />li <br />Dates. Place, and Circumstances <br />8 <br />14 <br />