HomeMy WebLinkAbout14050002 Application G.,�,� °�a`��L .
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— Department of Community Services 1 Civic Square,Carmel, Indiana 46032
l�'�IA�� (3I7)571-2444 phone (317).571-2499 fax www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
❑ ORIGINALPERMIT ❑ RENEWAL
1. APPLICANT INFORMATION
a. ���� , � � O�
last name -frst name mitldle name
b. (o I � � N Ge��l�er�e�l �y � S��en-S /�(/ �
home address city state zip code
�. (3i�) �-i3 - ��µ� C�rneon rn�ok � �P�,� h com
home phone no. alternative phone no. �C��Ii \ email address �—
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d. � � Jo�C� �( � � x�'����'1�
business�name supervisor(if apphcable) business phone no.
e. � � ( � ��i. ll P l_InJ �I �g��
business addres. � city s at� zr�code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age.or older. ❑ 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 Title 35 of the
In�d/iana Code. If yes, explain below.
U NO ❑ YES Date/Location/Offense
c. Have you, within the past three (3) years, had yourmassage therapisPs license or permit denied
or/reGoked for cause by any governmental entity in the United States? If yes, explain below.
YJ NO ❑ YES Date I Location I Reason
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d. Attached is a copy of my Limited Criminal History report, which;was.proyided.to me;byth"e:lndiana
State,Police no more than thirty(30) days prior to'the date,orn,which l am sukimitting,thisappiication to
the/Gity of Carmel; + ,; .�,' , �,�, ' � '.- '
LYJ NO ❑ YES - -�. . . ` - - —. • . .
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
in�ruction before I was awarded my diploma or certificate of graduation.
� �l0 ❑ YES Name of school/institution
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
�I NO ❑ YES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$25 ,000 annual aggregate.
�NO ❑ YES .E}�Jp
C,� ��,�-�, �,s P�l-� b
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS. (
a�',�� '��Q� C� I� �l ��C� � \� t1 °�'
year occupation busine s name � city,state zip phone�no.
b.
year occupation 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 compiete copy of Carmel City Code Section 4-21 ❑ NO YES
State of Indiana )
) SS:
County of Hamilton)
I attest that all of fhe above information is true and correct to the best of my knowledge and belief. 1 understand
that any mate�ialty fa/se. misleading, or incomplete statement on this Application shall constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
-%��'��-- �ir,�' � YY11 ck �R�
Signature of Appiicant Name printed
Subscribed and Swom to before me this �J`� day of , 20�
Pn• o PAMELA K. LUX � Q� �
2 svAl County of Res: Hamilton ��I. �
My Comm.EXpites 4-25-2015 signawre of Notary
N°' Comm. No. 564882
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l�ame Printed
My commission expires on , 2d5
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