Form: massage-reflexology-license-application

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Massage / Reflexology License Application

Fee: $200.00

License Term: July 1st thru June 30th

Owner of Establishment Where Therapist Will Practice (Business / LLC/ Corporation Name):

Name of Establishment

Federal ID Number (FEIN)

Business Address

Street Address

Business Address

City

State/Province

Zip/Postal

Business Phone Number

Agent / Manager of Business:

Licensee / Therapist Name

First

Middle

Last

Licensee / Therapist Home Address

Street Address

Licensee / Therapist Home Address

City

State/Province

Zip/Postal

Licensee / Therapist Phone

Licenses / Therapist Date of Birth

Licensee / Therapist Driver's License Number

Upload Picture of Licensee / Therapist Driver's License

Maximum file size: 52.43MB

Upload Copy of current/valid DSPS Certificate

Maximum file size: 52.43MB

Wisconsin Certification / DSPS License Term:

Have you ever been convicted of a felony?

Yes

Have you ever been convicted of violating any law in the State of Wisconsin?

Yes

Signature

Date

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