HomeMy WebLinkAbout14050001 Application G`,�,� °�`'��t .
.. Clt of Ca�el
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=� Department of Community Services 1 Civic Square, Carmel, Indiana 46032
INDIA�� (317)571-2444 phone (3 U)571-2499 fax www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
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ORIGINAL PERMIT AL � OOO
1. APPLICANT INFORMATION
a. ��Q�4�221� , ���5'�
last name first name middle name
b. .�v�_C�� -�� J��
home address city state zip code
�. c31�'-�d(a�S�'�d � � ����-
home phone no. altemative phone no. email address
d. � �C,UUI �l�e - - a
business nam supervisor(if applicable) business phone .
e.
business address city state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ❑ NO �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.
�NO ❑ YES Date/Locatlon/Offense
/ _.
c. Have you, within the past three (3) years, had your massage therapisPs license or permit denied
or revoked for cause by any governmental entity in the United States? If yes,.ezplain below.
NO ❑ YES Date/Location/Reason
�
d. Attached is a copy of my Limited Criminal History report, which was�provided to�me by,tfie;lndiana
State Police no more than thirty(30) days prior to the date on which�l.amsubmitting�this"application to
� r n�p�-uJ�� � . �e
the City of Carmel; ��I'1S ��' ,,r;,ti� r„ ,,,1 ��t i'; • '�!" '
� ,' ;; , .°vi �, r:�^, � ' - ..
❑ NO ❑ YES — _.
3. MY QUALIFICATIONS:
a. I am a graduate of a school or institution ofmassage 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.
-� q�'/��JJ_�e
❑ NO YES Name of school/institution�S���f �P���/�i����/� ^ � /
�' ��,��.�� , ;
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution'of'massage '
❑ NO �1 YES
/ -
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
❑ NO �j YES
4. MY EMPLOYMENT HISTORY FOR P ST THREE (3) YEARS.
a�/L,��� � � L��'* / �'cl c� /
year oc 'a4piV business na city,state zi 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 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 informa ' n is true and correct to the best of my knowledge and belief. 1 understand
that any materia false. mislea ' , or incomplete statement on this Application sha/l constitute grounds for
denial of this plication an rev ation o(my Massage Therapist Permit.
� � � _
Si r of Applicant Name printed
Sub cribe and Sworn to before me this �"� day of (� , 20�
,s PAMELA K.LUX
z S� Counry ot Res:Hamilton s�9 at��e� �
My Comm.Expires 4-25-2015 ,�n m � �� ,/ ��
IA�P Camm. No.564882 •S T�
Name Pnnted
My commission expires on '' ��20 �5
SeazchResults Page 1 of 1
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