HomeMy WebLinkAbout07040197 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
:).'i OF CA..RA(.
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INDIAt'l~
317 571 2444 phone
3175712499fax
www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
o ORIGINAL PERMIT
o RENEWAL
1. APPLICANT INFORMATION
a.
A-\u\n\i\E'_
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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home phone no. alternative phone no. em ail address
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state
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zip code'
c.
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business name \
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business add ess JU
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supervisor (if applicable)
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business phone no. .
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city
IN
state
zip code
2. APPLICANT BACKGROUND INFORMATION
a.
I am eighteen years of age or older.
D NO
~ES
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.
~o 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 entity in the United States? If yes, explain below.
dNO 0 YES
Dale I Location / Reason
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 ot Carmel;
o NO r~/YES
517
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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 fi' YES Name of school/institution ,\-Zn.~\o.V\ r.o(\p~e,
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
D NO 0/" 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 ~YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a~ ~~~~nAsYi\ ~s~~m~~e \ \~;~~\\S,llil
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phone no.
b. ceo --610 \ .
year
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city, state zi~ '
phone no.
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year occupa on
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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
D NO
o/YES
State of tndiana )
) SSe
County of Hamilton)
I attest that alt of the above information is true and correct to the best of my knowtedge and belief. I understand
that any materialty false, misteading, or incomplete statement on this Application shalt constitute grounds for
denial f this application and/or revocation of my Massage Therapist Permit.
Subscribed and Sworn to before me this
Amber Mid e ,
Name printed
:2fn-H-t day of AD!'I'I
I
, 2r/J!l
My commission expires on
,20_
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