HomeMy WebLinkAbout07040125 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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3175712444phone
317571 2499 fax
www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMll.:'. _$_40.QO..
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o ORIGINAL PERMIT o RENEWAL :iUg=::-~'" :"~-:'~-=:1 \ \\\1
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1. APPLICANT INFORMATION
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last name first name middle name
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b. -F-n I
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orne address . ' city state zip code
c. 3\.1 (1) 8- If.~~ S; ~<+~ - I (~~
home phone no. alternative phone no. email address
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ljuslnes~ name supervisor (ifap icable) business phone no.
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usiness address city state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or oider. 0 NO I::IYES
b. Have you, within the past three (3) years been convicted, or plead Nolo Contendere for any crime of
unlawlui deviate conduct, deviate sexual conduct or sexual conduct as defined in Title 35 of the
Indiana Gode. 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 e~tity in the United States? If yes, explain below.' '
.~ 0 YES Date I Location I Rea~on - . '.' .
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;
.Z"NO 0 YES
ltll'7J107 . c.MQed - ~ .J\Lo.d.t;\}Dy ~. . rJL
3. MY QUALIFICATIONS:
a, , 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. 6. & ~ \ : .l\ '
CJ NO ~ES Name of schooi I institution ~'c..~_'" t; .... ...... t.d---:+h~c.l
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institutio~ Of~~\ss~
CJ NO ~YES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
CJ NO ~
4. MYEMPLOYMENTHISTORYFORPASTTH~EE(3)YJ;ARS. (I ~ Y~<>,~s) 3ti
ms,,\. . f\'-ll.'l"7c.:')n \-\~<:: .
a~/'\\,~r<1~;c".x-- fV~L-,[n,,\~,jes -r1-jJ.~c:' ~tt3-lr~8
-~ occupation business name city, state zip phone no.
year occupation
city, state zip
phone no.
b.
business name
year occupation
business name
city, state zip
phone no. ,
c.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4.21 CJ 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
denial of this application and/or revocation of my Massage Therapist Permit.
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Signature of Ap nt ~ Name printed-;"
Subscribed and Sworn to before me this o! f, day of ~ . 2~42'
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Signature of Notary . ,.,
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Name Printed rM y<t/J ~
My commission expires on/6 ~ , 20{l jl