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River <br />I:x063 thwio Paiku �t <br />I I Itr, 51N 5433(1 <br />MASSAGE THERAPIST LICENSE <br />APPLICATION <br />c c 14 Lt S <br />Incomplete applications will not be processed. If a question sloes not apply, please write <br />"N /A„ <br />1. Name ill �6 <br />First J Full Middle Maiden Name last <br />2. Home address Beet P-a(9)r) ,. J Stat ��oldFlV+1 pml� M� �-N <br />StrCity Zip <br />3. Home phone_ Alternate phone; <br />4. Name of establishment where massage will take place—ToyS� <br />5. Establishment address 1' L L�R+?S _ NW 6/k _ MN 51-330 <br />G. Establishment phone 30- <br />7. Owner of establishment where massage will take place Pc-, f 4i L4 _ <br />11 � <br />8. Establishment manager A 4� L <br />9. Are you licensed in any other community? Yes JI No ❑ If yes, where? <br />10. Have you been denied a massage license by any licensing authority? Yes ❑ No14 <br />If yes, indicate licensing authority <br />11. If you have ever used or been known by a name other than the true nam ven above, list <br />such name(s) and information concerning dates and places used._ AI( <br />12. Addresses at which you have lived during preceding five years. (Begin with present address <br />and work back). Attach additional sheets if necessary. <br />13. Names and addresses of your employers, if any, for the preceding five years, including self <br />employment. (Begin with present or last occupation and work back.) Attach additional sheets <br />if necessary. <br />Ever Street AddressA Cit—� Dates <br />rf <br />r 303 <br />aro q r- 3002-1 <br />Phone: 753.635.1000 <br />Fax: 763.635.1090 P O Mf E R E d 8 T <br />www.ElkItiverMN.�n IINATUREI <br />