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�