HomeMy WebLinkAbout07040034 Application
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City of Carmel
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Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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3175712444phone
3175712499 fax
www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
~ORIGINAL PERMIT
o RENEWAL
1. APPLICANT INFORMATION
a.
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last name
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first name
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middle name .
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home address / city
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home phone no. alternative phone no.
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business name (j (/ supervisor (if applicable)
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stale
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zip code
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email address
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business phone no.
state
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zip code
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business address city
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2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older.
o NO
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b. Have you, within the past three (3) years been convicted, or plead Nolo Contendere for any crime of
unlawful deviate conduct, deviate sexual conduct or sexual conduct as defined in Title 35 of the
Indiana Code. If yes, explain below.
IDto 0 YES
Date I Location I Offense
c. ,Have you, within the past three (3) years, had your massage therapist's license or permit denied
or revoked for cause by any governmental entity in the United States? If yes, explain below.
gNO 0 YES
Date I Location! Reason
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d. Attached is a copy of my Limited Criminal History report, which was provided to me by the Indiana ,
State Police no more than thirty (3D) days prior to the date on which I am submitting this application to
the City of Carmel;
o NO ~YES