HomeMy WebLinkAbout07050039 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
3175712444phone 3175712499fax www.carmel.in.gov <F070S'ODOGj
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
oj ORIGINAL PERMIT
Cl RENEWAL
1. APPLICANT INFORMATION
a.
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last name
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first name
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middle name
b.
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home address
city
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state
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zip code
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(50) f/'5-Cf"l5'4
home phone no.
(317 ) 250- 77 3 7
alternative phone no.
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email address / - ..,
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business ame
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supervisor (if applicable)
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business phone no.
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business address
city
state
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. CJ NO -d YES
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 Titie 35 of the
Indiana Code. If yes, explain below.
dNO Cl 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 entily in the United States? If yes, explain below.
d NO Cl YES
Date / Location / Reason
d. Allached 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;
Cl NO rsi YES
117 107
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3. MY QUAUFICATIONS:
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 tive hundred (500) hours of supervised
instruction before I was awarded my diploma or certificate of graduation.
D NO EYES Nameofschool/institution.7VPuL 1l.'''-''pY!4.f''c.. /lAaS!;Q5''(
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
D NO
oi YES
C. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
D NO gI YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. 2004 /iA~(~J/ 7J.'''Y''$f r;.,....J. ~pq T"'~'q;1..P-!;,>,.1i1J4"Z"'1 L?I7) 972 .4747
year OCCUpatl n business name city, state zip / phone no.
b. 2 Ot:?'5 (<-$-1....,,, ;;",,"c<
year occupation
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business name
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City, state Zip
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phone no.
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year occupation business name city, state zip ~ phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
ri YES
State 01 Indiana )
) SSe
County 01 Hamilton)
I atlest that all 01 the above inlormation is true and correct to the best 01 my knowledge and beliel. I understand
that any materially lalse, misleading, or incomplete statement on this Application shall constitute grounds lor
denial 01 this application and/or revocation 01 my Massage Therapist Permil.
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Subscnbed and Sworn to belore me thIS 4- day of mcu..r
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Signature of Notary
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Name Printed
My commission expires onfJp'lJl c9 5 , 201.J.