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<br />~IAR-27'-2001 10' 03 <br /> <br />612 985 44'39 P,03/04 <br /> <br />. <br /> <br />Have YOll ever had a li~nse deni&!, revoked or suspended? <br />If yes, please cOIllplerc the fOllowing: <br />Where? Wl1en? <br /> <br />Type of license <br /> <br />Reason for novocatloll <br /> <br />Have you ever been committe<;! for one of the following? <br />Psychological prObJell'li_ 1l1ebrialion_ Dcui Use_ AlcollOllJse_ <br />Other <br /> <br />A! wlul.t location(s) in the City will you perform massages? <br /> <br />WUll'OU be le-asing projletl)i for tllerapeutic Il1iIssaga business? Yes_ No_ <br />If yes, please provide a copy of It.e lease lIIld the owners name. address and telephone number: <br /> <br />List tile name alK! address of two person. who are residents of Dakota COWl!)' who can altos! to your <br />character: <br /> <br />Telephone :0<0. <br /> <br />Telepllone No. <br /> <br />Please provllle your prlncipal address for the last 10 yeats: <br /> <br />Have you received forma! !l'3ining in massage) Yes_ No_ <br />If yes, please complete L'le follOWing: <br /> <br />Name of School and Address <br />DalOs at!ended <br />Hol.IIs of training <br />Diploma received <br />By whom is the school accredited'? <br /> <br />L_____ _ _ <br />