HomeMy WebLinkAbout07040080 Application
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Department of Community Services 1 Civic Square,' Carmel, Ind,ia_n.":~~032 ! 10/
3175712444phone 3175712499 fax www.carmel.in.gov ._--" i
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'APPLICATION -' MASSAGE THERAPIST PERMIT - $20-:00
- ~'i OF CA.~
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lNDlA~~
~GINAL PERMIT
[J RENEWAL
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1. APPLICANT INFORMATION
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last name
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~om8 address .. ~ . state
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home phone no. alternative phone: no.
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a.
b.
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first name
middle name
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zip code
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mail address
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city
r ral{~1
f!1t;')ct7)-O(P(P7
bUSiness phone no.
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zip code
d.
e.
business address
state
2. APPLICANT BACKGROUND INFORMATION
o NO
~ES
a. I am eighteen years of age or older.
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.
~ 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 beiow.'
~ DYES
Date I Location I Reason
d. Attached is a copy of my Limited Criminal History report, which was provided to me by,th~ Indiana I
State Police no more than thirty (30) days prior to the date on which I am submitting this application to
the City of C~el;
D NO wlYES
3. MY QUALIFICATIONS:
a. 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 compietion of at least five hundred (500) hours of supervised
instruction befor} I was awarded my dipioma or certificate of graduation.
o NO ~ YES Name of school I institution ::J.t,Je'ow... 'l3~ iW.r c.. (~ ,... M~
b.
i have attached a copy of my diploma or certificate of graduation from an accredited school or
institutionofma/ge A Ul~ crt o?l'!1l>f. ~ :z:13C. DlfLo'\tou... LoJill C\yv,.v.e
o NO cr YES rr ~v ,. ~~4,
.
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c. I have attached,proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 ,annual ,gregate.
o NO wi' YES
4. MY EMPLOY~ENTHISTORY FOR P.~ST THREE W YEARSNr'l'V< , ,(i" ..rf'l
a.'l..oCo-Pr.u-X, ~a.f"/.,,' ,It;.ftlZ-''
year occupation iness nam~, ci state zip
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phone no.
b. '\
year occupation
. c.
year occupation
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business name
city, state zip
phone no.
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bus1ness name
city. stat. zip
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
~S
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
deniai of this application andlor revocation of my Massage Therapist Permit.
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U. tfltJ A 1_-" hi, LA k +t,
Nam~ted
Subscribed and Sworn to before me this ~day of
A. OU-CYl
,260
Na . Printed ' ,
My commission expires on f?Lb.
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;2.0 . 20.f21: