HomeMy WebLinkAbout07040070 Application
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! LJ \j \ l~Department of Community ServIces 1 Civic Square, Carmel, Indiana 46032
'I' L--'-lNDfA1"~ 3\175712444 phone 3175712499 fax
'! www.carmel.in.gov
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APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
)(ORIGINAL PERMIT 0 RENEWAL
1. APPLICANT INFORMATION
a.
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last name
first name
middle name
b.
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home address
city
state
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zip code
home phone no.
alternative phone no.
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email address
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c.
3/1-81'3' 61.;2.'-/
d.
business name
supervisor (if applicable)
business phone no.
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city
state
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. D NO ):( YES
b. Have you, within the past three (3) years been convicted, or plead Nolo Contendere for any crime of
unlawful deviate conduct, deviale sexual conduct or sexual conduct as defined in Title 35 of the
Indiana Code. If yes, explain below.
)(NO 0 YES
Date / 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 entrty in the United States? If yes, explain below.
)l( NO 0 YES
Date J Location I Reason
d. Attached is a copy of my Lim~ed Criminal History report, which was provided to me by the Indiana
State Police no more than thirty (30) days prior to the date on which I am submitting this application to
the C~y of Carmel;
o NO ~YES
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 completion of at least five hundred (500) hours of supervised
instruction betore I was awarded my diploma or certificate of graduation.
D NO J:i(" YES Name 01 school Ilnslllution P/I-'-N'r "2,-LAQ-t :5choO\ ~.
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b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
D NO
.la' YES
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 ,e( YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
an #1Msi46-k- 'rfh~t;~-T )~(J;
year occupation business ame
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city, st;fte zip /
phone no.
b )
~ occupation
business name
city l state zip
phone no.
c. fui1M4-0 r
year occupation
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phone no.
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5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel Crty Code Section 4.21
D NO
Ji( YES
State of Indiana )
) 55:
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 application a or revocation of my Massage Therapist Permit.
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Subscribed and Sworn to before me this
Name printed
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ignature 01 Notary / !
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My commission expires on kb. ;(0 , 20 () 1