Laserfiche WebLink
<br />MRR-2'7-2<lQl 10: ro <br /> <br />612 985 4499 P.03'84 <br /> <br />Have you ever had a liceIUe deniOO, ~voked or suspended? <br />If yes, please COmplete the rollowlna;: <br />Where? Wtu:n? <br /> <br />TYJ'e of iicense <br /> <br />Reason tor rewx:alloll <br /> <br />Have you ever been committed for one of the foHowing? <br />Psychological problelllS_ Inebri.ation__ Druit Use_ Alcohol Use_ <br />Other <br /> <br />At what location(s) in the City wUl you )lerform massages? <br /> <br />Will you be Ie-Wi properly for llIerapeutic II'-ilssage business? Yes_ No_ <br />If Yes. please provide a copy of tt.e lease and the owners name. address and telephone: oumber: <br /> <br />Ust the name and address of rHo persons who are reSIdents of Dakota County who can atte't to your <br />character; <br /> <br />Telephone "'0, <br /> <br />Telephone No. <br /> <br />Please provide your prlllcipal address for the last 10 years: <br /> <br />Have you received formal traicing in l11llssage'? Yes_ Na_ <br />If yes. please complete me follOWing: <br /> <br />Name of School and Address <br />Dare. altended <br />Hours of ll'ailling <br />Diploma received <br />By whom i! the school accredIted? <br />