HomeMy WebLinkAbout07110151 ApplicationG`if Of CA /?,if,
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City of Carm
Department of Community Services 1 Ovic Square, Cannel, Indiana 46032
317 571 2444 phone 317 571 2499 faz vrn .carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
V ORIGINAL PERMIT ? RENEWAL
1. APPLICANT INFORMATION
a. !/1.6'1. n.
last name lir name
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middle name
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b. 3aY ?t /J?r . Dm i?i?m tt i
home address city state zip code
c. 1;3?7)$9c-1??27 k/))957 -l?l4A e 1
home hone no. alternative phone no. email ddmss
d. 317) 91 5-lobl 3
business name sup/e?wsor f applicable) business phone no.
e. /rnirn
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business address city state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ? NO W '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 Title 35 of the
Indiana Code. If yes, explain below.
R(NO ? YES Date / 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 govemmental entity in the United States? If yes, explain below.
V`hIO ? YES Date / Location / Reason
d. Attached is a copy of my Limited Criminal History report, which was provided tome 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;
? NO BYES
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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.
11 NO Zr YES Name of school / institution 6 P?d A k
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
? NO Q YES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggre ate.
NO ? YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS. WK/
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year occupaton business ?wne city, ship phone no.
b.
year ocwpalion business name city, state zip phone no.
C.
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 ? NO YES
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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nature of pplicant J Name printed
?ed and Sworn to before me this ay of D yl 20
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My commission expires on _r(& ?- ?C , 20M