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CITY OF LITTLE CANADA <br />APPLICATION FOR MASSAGE THERAPIST LICENSE <br />Annual License Fee - 875.00 <br />\,./New Application <br />Please complete the following. 1 <br />1. True Name (.;/'ilI�,LAC--,)�/L�� 6 -8/1.0 <br />LAST FIRST <br />Renewal Application <br />FULL MIDDLE NAME <br />2. Residence Address C5/1 ) /`r, / <br />SO— . �` <br />�>GJ // <br />3. Residence Telephone ; �, %U — , �; .�U" („ ,`_�; � � <br />4. Business Address ,.:? �7/: „i riff 4 ., �'37:2\-Cr�_./ <br />5. Business Telephone ' % : S 3() <br />6. Social Security Number <br />7. Driver's License NumIt <br />8. Date of Birth <br />9. Place of Birth <br />10. U.S. Citizen? Yes No <br />Naturalized? Yes No <br />If yes, give date and place <br />Attach a copy of the naturalization papers, <br />1 1. 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 />8 <br />19 <br />�1 <)j <br />