HomeMy WebLinkAbout07070105 Application
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~i. OF CA.l4r.
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City of Carmel.
Department of Community Services 1 Civic Square, Carmel, Indiana 46032 :
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317571 2444 phone
317571 2499 fax
www.canneLir)..gov
APPLi.ICATION ,. ,MASSAGE_THERAP-JST PERMIT. $20.00
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X>l ORIGINAL PERM ir I EI-RENEWAL i7'7 01 05
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1. APPLICANT INFORMATION
a.
EIfel{)
middle name
b.
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city ,
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, alternative phone no. . .
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state zip code I
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business phone no.
home address
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c.
home phone no.
d, Lv.\~J W&VlJS
~Siness name
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supervisor (if applicable)
e.
state
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city
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zip code
business address
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older.
o NO
Ii'"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.
,2( NO 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.
a{NO DYES
Date I Location I 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 of Carmel;
D NO 'sz/ YES
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3. MY QUALIFICATIONS:
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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.
I:J NO (2( YES NameOfSChOOI/institution~,~~ ~Sl~% CoII~(2../
b.
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
I:J NO pi" YES
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c.
I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250.00q arinualaggregate.
I:J 'NO . V ~ES
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4. MY EMf>LOYMENT HISTpR
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',\ " year 0 upation
FOR PAST THREE (3) YEARS.
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b.
year occupation
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C.
year occupation
business name
city, state zip
phone no.
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business name
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city. ~tate zi.,\
. ' .
phone no.
5. RECEIPT OF MASSAGE THERAPIST PE~MIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
I:J NO
.i( YES
State of Indiana )
) SSe
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 an materially false, misleading, or incomplete statement on this App . ation shall constitute grounds for
denial this application ~or revocation of my Massage Therapist P
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Subscribed and Sworn to before me this
Na~~~
/3 dayof '- ~<r
,20DJ
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Signature of Notary
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Name Printed
My commission expires on~:? 20 IS-