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�l{li CA� fla-�( k <br /> MASSAGE THERAPY LICENSE APPLICATIt N'b/ ,,,.4, , y] <br /> PART I -- GENERAL INFORMATION 1 <br /> 9 ci 5/1 a PI <br /> Directions: If the application is by an individual, by such person; if by.e partnership, by one of <br /> the partners; if by a corporation, by an officer thereof. <br /> Specify Type of License: Xi New (first application) 0 New(Name and/or owner change) <br /> Specify Type of Business: <br /> 0 Limited Liability Company <br /> ❑ Individually Owned 0 Other <br /> ❑ Partnership <br /> XCorporation <br /> �^s �x q . r s lx 3; <br /> w^. r.., 41 t T^�. i a rr a .7`i i .ti s'.. t e_..t .€^�KI i 4E Sss1^ H',�+tT�{ 7 0i ` i y;Vx <br /> t�_ � 't u�T y9s `,Jij,Y�n��ip4+,�� #�1j' � �•iwl�Skl,L�*2S jwA%Elk?V=i'=...e:. .tc;'i <br /> 1-44 ---5 .//Y2 . .--i3lc:), ///14". <br /> Licensee Name: ,_c1, <br /> Trade Name or DBA: �,,� �/� �� �e � ����0/09 5:<"- /License Location (full address)• " �" t� ��'%�` /9/0 4 /,/ <br /> License Location Phone: Q,,�rr' 'i</..7 4 0-71 <br /> f <br /> License Period: / 11/Lt7i/ /3// /5 <br /> List of all current employees andior independent contractors (including applicant/owner, <br /> manager(s), assistant manager(s), partners of a partnership, officers of a corporation and <br /> therapists): Percentage of <br /> interest in <br /> Date of partnership or Practicing <br /> Full Name Address. Birth Title* corporation Massage <br /> ; -Oji 1 1 AL. Yes pNo <br /> P <br /> `` --- ,, i , os.-72i7-7; Yes No <br /> 1):: , <br /> A-- <br /> -vlbn, I , _ r - - ' I - Mafia Yes No <br /> 1 <br /> `• kS _ 1Z Yes No <br /> t <br /> ��._�U <br /> i ��, .• , w4Ail . - , w Yes No <br /> " „� �_ ! L' e S <br /> �� Yes No <br /> _ ia� <br /> '� {icantlowner. <br /> "Pa I, +mortal-- history statement and background check must be completed for app <br /> Part lll, personal history statement and background check must be completed for all others listed above. <br /> (Attach additioial sheets if necessary_ <br /> 1 1,fkP 15-9\ktre- ,p.e,,-EcY-`c`4 tit ,e,_, <br /> { i t <br />