HomeMy WebLinkAbout07040150 Application
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City of Carmel
Department 01 Community Services 1 Civic Square, Carmel, Indiana 46032
INDIAl'I~
317 571 2444 phone
3175712499 fax
www.cannel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
rs/ ORIGINAL PERMIT
o RENEWAL
1. APPLICANT INFORMATION
a.
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last name
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middle name
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home address city
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state
4-b~oS
zip code
c.
(:bIt \ 332- '6iD/P
home phone no.
(311-") 33;).-3/0(P
alternative phone no,
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d.
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J supervisor (if applicable)
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( 30,) S//tJ-tXt,OO
business phone no.
e. 2.001 E. i6lt,t Sf. J -#= f3p~
business address
city
Jjj tlbo3Z
state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. D NO w/vES
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.
~NO 0 YES
Date / Location I Offense
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,
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.
rsI NO 0 YES
Dale! Location I 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 (30) days prior to the date on which I am submitting this application to !
the City of Carmel; I
o NO ~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 least five hundred (500) hours of supervised
instruction before I was awarded my diploma or certificate of graduation.
D NO ~ YES Name at school! institution Professional (Janas];;3 I-tlufe
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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 [3'" YES
c. I have attached proof of my professionai liability insurance of not less than $100,000 per occurrence and'
$250,000 annual aggregate.
D NO iiY YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. ~M1 Coova/,nCLhw- Tr.dJ~ AukH 0.creoJi/Yi lndi~AA/JlJiis,IN %ZPZ (:!;l7)327. 7'-f/P~
year occupation businejs name city, state ~p phone no. I
(!JR ) 577- OOzs
year
rna~aae -rhervfrsJ {J;MJ~ fun.ds Su!OJlt'^
occupatibn business n me
iffX7t (Yla,~0~ne1khttl Ceder TwianD.ODliS, IN i/6Z2/ (yI)(o:!lf- Jjp
busi ss !Jlme city, stats zip phone no.
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city, state' zip
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b. :J.b05
phone no.
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year
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
D NO
Iii 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 beliel. I understand
that any materially lalse, misleading, or incomplete statement on this Application shall constitute grounds for
denial of this application and/or revocat1l:Jn of my Massage Therapist Permit.
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Subscnbed and Sworn to before me thiS
~ J:>. CCU'Y-
Name printed
:lOr'" day of -A f)r; J
I
, 20ril
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Name Print d
My commission expires on
.20