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<br />MAR-27-2Q"l 1":03 <br /> <br />612 985 4499 P.03/04 <br /> <br />, <br /> <br />Have )'ou over had a Iicenae denied, revoked or suspended'? <br />If yos. please COl!Iplcu: the fallowing: <br />%e~? W~n? <br /> <br />Type of lk:ense <br /> <br />Roasoo for revocation <br /> <br />Have you ever been committed for one of the following? <br />Psychologicalproblelll$_ lnebriation_ Drui Use_ Alcohol Use_ <br />Other <br /> <br />At what loeatlon(s) ill the elly will you perform massages? . <br /> <br />WlIl you be le-asini propeny for merapeulic massago bUsiness? Yes_ No_ <br />rr yes. please provide. copy of tl:e lease and the OW!l8rs name, llddross and telephone numbee <br /> <br />List the name aad address of two persons who are residents of D.ko13 COilllly who can atte't [Q YOOI <br />c!l3racter: <br /> <br />TelephOne ~o, <br /> <br />Telephone No. <br /> <br />Please proviae your principal address for the last 10 years: <br /> <br />Have you received formal u'aioing in massage' Yes_ Na_ <br />If yes. please complete Lie follOWing: <br /> <br />Name of School anc Address <br />Dares attended <br />HO\lfs at training <br />Diploma received <br />By whom is the school accredited? <br /> <br />1_ _ <br />