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HomeMy WebLinkAbout14060037 Application (2) � 3.. MY QUALIFICATIONS: a. I am a graduale of a school or institution oPmassage�therepy which is accredited by the Indiana Commission of Proprietary Education o��Similar-state�agency or commission of a state other than Indiana that required.my successful completion of at least five hundred (500)hours of superoised instruction before I was awarded my diploma,or certificate of graduation. ❑ NO � YES Name of school/institution ,Y�( �e�!{'�l ��G�l�`"'!� 6. I have�attached�a copy of my diploma or certificate of graduation from an accredited school or institution of massage - ❑ NO L'f YES c. I have attached proof of my professional liatiility insurance of not less than $100,000 per occurrence and $250,000 annualaggregate. ❑ NO 'U YES 4. MY EMPLOYMENT HISTORY FOR PAST iHREE�(3)YEARS. a. �DIU �VY O��� Y � Cctr/�?f�/�l�yc�3� Ci 8 y�y/ba year occupation tiusiness name� city,state�zip phone no. b. �2� L__N� 6��6 y ,�a /'c�rnei,rnl��t�o�� �3� � c�-yroo year occupation business name. ciry,state-zip phone no. � � � �� ��dvi5 �N �ba5a 3�� �-�q�o year cupanon u mess name city,state zi� phone no. 5. RECEIPT OF.MASSAGE THERAPISTPERMIT ORDINANCE I have received a�complete copy of Carmel City Code Section 4-21 � NO ❑ YES � State of.lndiana._ ) J SS: Countyof Hamiltorr) � - 1 attest that all of the above.information is true and correct to the best of my knowledge and belief. l understand , • that any,materially false; misleading, or incomplete,statement on"this.Application shall constitute grounds for . - den�al of++tfiis application and/orrevocation-.of my-Massage Therapist Permit. �.U� .� �'���i�PJ� �iiGn�n B �r�(:c/Ql! SignaNr Applicant Name'piinted . Subscri6ed and Sworn tqbefore me�this_�_.day of , 20�y "w%. .�� , � 'PAMELAJTATOM �Y 1 �i `,� ��`'.: � �MadonCoumy . .� - � • �' , -�� �` My�CommissionExpires Si�naWreoCNOtary � �; �=':::.-::� FebNary 10,2019 ����/ p.:""�"'."�._� ; - . . Name Prin�ed' - ' My commission expires�.on�'-� , 20�