HomeMy WebLinkAbout07040228 Background Check
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 before i was awarded my diploma or certificate of graduation,
o NO
Z YES
Name of school I institution Ihc!i9h4 r3i1Siu",;;5 CollreJP,
b, I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o NO
IdI YES
c, I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate,
o NO
)Y YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a,
year occupation business name city, state zip phone no,
b,
year occupation business name city, state zip phone no. I
C,
year occupation busIness name city, state zip phone no. I
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
a" YES
State of Indiana )
) SS:
County of Hamilton)
f attest that all of the above Information is true and correct to the best of my knowledge and belief. f understand
that any materially faise, misieading, 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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~~~~ f /p~ Name printed
, Subscribed and Sworn to before me this :< ?Mday of +;/ ' 20122
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Signature of N ry I
'J;t( V A. W~dd;iICdon
Name Printed/ J I
My commission expires on , ~O