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<br />MAA-27-2001 11;): e3 <br /> <br />612 985 4499 P.03-'04 <br /> <br />, <br /> <br />Have )'011 ever had a license denied, revoked or suspended? <br />Ii yes, please complete the followiilll: <br />Where? When? <br /> <br />Type of EcellSe <br /> <br />Reason for revcx:atlon <br /> <br />Have you ever been COmmilted for one of we following? <br />PS'jchological problelllS_ lnebriation_ Drug Use_ Alcohol Use_ <br />Other_ <br /> <br />At what locatlon(s) in me City will you ])alform massages? <br /> <br />wm you be leAsing property for illerapeutic massage business? Yes_ No_ <br />tf yes, please provide a copy of tte lease and the OWIlllU name. address and telephone number: <br /> <br />List the natl'l~ and address of IWO persons who are residents of Dakota Counry who can amm to your <br />character: <br /> <br />Tel~phone No, <br /> <br />Telephone No. <br /> <br />Please provlae your prJncipal address for the last 10 years: <br /> <br />Have you received formal traJnlng in massage? Yes_ Na_ <br />If yes. please complete L"e following: <br /> <br />Name of School and Address <br />Dales attended <br />Hours of training <br />Diploma received <br />By whom is the school accredited? <br />