HomeMy WebLinkAbout07040034 Application (2)
3. MY QUALIFICATIONS:
b.
I am a graduate of a school or institution of massage therapy which is accredited by the Indiana
Commission of Proprietary Education or similar state agency or commission of a state other than
Indiana that required my successful completion of at least five hundred (500) hours of supervised
instruction before I was awarded my diploma or certificate of graduationl\., /J. _ 0--,1..
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D NO ~ YES name of school I institution ski t1 f j.fL)ti-;r( j!: tr/
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
rz( YES
D
NO
a.
c.
I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250.000 annual aggregate.
D NO r:/ YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
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a~" " ,.7 .~" q ~ U;,eif/JI(..:t:/J
'7~ ~ar' ace ion business name ~' / city, state .
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b.~ I!!f:J!ir ~ sY ~;hJ
year ~ ~e name,; J.v:.. city, state
I f1~ (_ 0' HIM..)' 'I'? ~~.
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-----ytar business name U tt city, state .
3J 7-J"'6-15J-o
phone no.
31?-f!/(,-7SSP
phone no.
317- ,r/? .75.10
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
D NO
~YES
State of Indiana )
) SS:
County of Hamilton)
I attest that all of the above information is true and correct to the best of my knowledge and belief. I understand
that any materially false, misleading, or incomplete statement on this Application shall constitute grounds for
denial of t 's application and/or revocation of my Massage Therapist Permit.
Subscribed and Sworn to before me this a,-t/>day of ,f/f!.rd7
,20d
My commission expires on hi? J 0 ,20!23
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