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<br />,- <br />, <br /> <br />MI'If<-2'?-2il01 10: B:l <br /> <br />612 985 4499 P.0~'04 <br /> <br />Have ).ou ever hid a license denied, revoked or suspended? <br />If yes, please complete the following: <br />Where? When? <br /> <br />Type of license <br /> <br />RcUQll for revocation <br /> <br />Have you ever been committed for one of Ille foliawing? <br />Psychologlcalproblelll$_ 1Mbriation_ Drug Use_ Alcohol Use_ <br />Other <br /> <br />Ar what locatlon(s) in the City will you perform massages? <br /> <br />Will you be leasing property for lllerapeutic rr.aS6ige business? Yes_ No_ <br />If yes, please provide a copy of the lease and the owners name. address and telephone number: <br /> <br />List the name and address of r;vo persons who are residents of Dakota CO\1Ilty who can attest [Q yo"r <br />character; <br /> <br />Telepho/lC ~o. <br /> <br />Telephone No. <br /> <br />Please provIde your principal address for the last 10 years: <br /> <br />Have you received formal u-aining in massage? Yes_ No_ <br />If yes, please complete [.~e follOwing: <br /> <br />Name of School and Address <br />Da'es attended <br />HOllIS of training <br />Diploma received <br />By whom is the schoo! accredited? <br />