HomeMy WebLinkAbout07040072 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmei, Indiana 46032
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317571 2444 phone
317571 2499 fax
www.carmeLin..gov
APPLICATION -MASSAGE THERAPIST PERMIT - $20.00
9 ORIGINAL PERMIT
D RENEWAL
1, APPLICANT INFORMATION
a, J:::l \ __.\..:.,-.,t--J
last name
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first name
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middle name
b.
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home address ~~\. '-Y city
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home phone 00. alternative phone no.
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state zip code
c.
email address
d.
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business name; "'1
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supervisor (if applicabl.e) business phone no.
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business address ~ city
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state
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zip code
2. APPLICANT BACKGROUND INFORMATION
a. J am eighteen years of age or older. 0 NO r:j. YES
b. Have you, within the past three (3) years been convicted, or plead Noio Contendere for any crime of,
uniawful deviate conduct, deviate sexual conduct or sexual conduct as defined in Title 35 of the
indiana Code. If yes, explain below.
'rjJNO DYES
Date I Location I Offense
c. Have you, within the past three (3) years, had your massage therapist's license or permif denied
or revoked for cause by any governmental entity in the United States? .if yes, explain below.
rjlNO DYES
Date I Location I Reason
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d. Attached is a copy of my Limited Criminal History report, which was provided to me by th'elndiana
State Police no more than thirty (30) days prior to the date on which I am sUbmitting this application to
the City of Carmel;
o NO fI.. YES
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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 ieast five hundred (500) hours of supervised
instruction before I was awarded my dipioma or certificate of graduation.
D NO
rp. YES
Name of school I institution V"-'pl.--lt-...t c......I I__j
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
D NO
t$. YES
c. I have attached proof of my professionai liability insurance of not less than $100,000 per occurrence and
$2.50,000 annual aggregate.
D NO tp. YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
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year occupation business name
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year occupation
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bus'i~;Jari:
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year occupation business name
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city, state zip 4u~'Z.. phone no.
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. city, state zip \ N .
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phone no,
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. city, state zip
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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 City Code Section 4.21
D NO
It4 YES
State of Indiana )
) SSe
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.
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Name printed
Subscribed and Sworn to before me this 5/-4 day of ADr; I ,20Ji]
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Name Print~d J
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My commission expires on
,20