HomeMy WebLinkAbout14050014 Application G..�Y °�AR`'TFL .
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= Department of Community Services 1 Civic Square,Carmel, Indiana 46032
IND1Al�� (317)571-24dd phone (3I7)571-2499 fax www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
❑ ORIGINAL PERMIT ❑ RENEWAL I�� 7 O O I�
1. APPLICANT INFORMATION
a. , )C'�\��S , ���1 G ���-22 Y1
last name frs[name middle name
b. � �JZ�J [�f'G�tl{' ���f. � � �� �OZ�J"�
home address state zip code
�. ��J�� - � �L.o ��1 lp� MAY 0 2 2014 wk<<Pf���l "I� C���!�(`�w
home phone no. ternative phone no. email address
d. V�iU:X�1'�GI.SC' �I `��-1 By ���S1 � �3��
business name supervisor(if applicable) business phone no.
e. l Q f'1'1`�-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.
LY NO ❑ YES Date/Location/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.
L] NO ❑ YES Date/Location I Reason
d. Attached is a copy of my Gimited Criminal History report, which�was�provitled to me:by the,lridiana
State Police no more than thirty(30)days prior to the date on which'hamisubmittingdhis application to
the City of Carmel;. � t., . 1ti ' . . • "" •:t' '. �• % , '
. � � � � f; . :� . �r, . , .,: i.' ,
O NO ❑ YES � � �
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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.
❑ NO NJ YES Name of school/institution �u Pv i ��ov� IM 4SS 4_C(J
1
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
❑ NO O�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 l� YES
r .
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. �1 4s �o �5-f�IOCX'��1C7.xP ��k,' �GCViht� � �� `�(G�jz �( �O'�3D�
year occupah business name city,state zip phone no.
b.
year occupation business name city,siate 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 Carmei City Code Section 4-21 ❑ NO 63 YES
State of Indiana )
) SS:
County of Hamilton)
I attest that all of the above�nformation,i 'true and correct to the best of my knowledge and belief. 1 understand
that any materially fa/se, �9+sleading,.or incomplete statement on this Application shall constitute grounds for
denial of thi app�fio�a'nd/�eGocation.o y Massage The�apist Permit.
� �/ ,� , �� /� / �� ��l/G( � c�0lil�S'
Signatur�A�licanl j % Name printed
�
Su scribed and Sworn to befo�e me this 2-"� day of �� , 20�
NICHOUIS F. MISHLER �o���
sF.ni, County of Res:Hamifton s� aNre of Notary
My Comm.E�yires 02-27-2019 �
�n Comm. No.624589 nl�� � �GS F• A.(;s �la.r
Name Pnnted
My commission expires on 41 2l , 20�
S2114 Welcometo Indiana Licensing
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Payment Receipt
If you paid for a certificate, it will be mailed on the next business day. You may use the
certificate below as a temporary until your order arrives.
If you selected the Free Certificate Printout, print and cut out the certificate below.
............................................................................................................................................................................................................................................................................
�a� Indiana Professional Licensing Agency
s glr�`'-• ����•~ 402 W. Washington Street, Room 1Af072
�:� Indianapolis, IN 46204
'�. I�
; �ese Mr210�3453
� Mia lC ones
has completed all requirements for licensure in Indiana as a
�
MA5��1Y'a�riA�IST j
To check the current status and egg���� date for this license, please visit
htto://mvlice ns e.in.q ov/e Ve rifica tio n
Michael R. Pence Nicholas W. Rhoad
Governor Executive Director
i........................................5tate...aE..In dia.na................................................................................................P..cotess iana.I..Licensing..lagency.............,.......s'
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,� Indiana Professional Licensing Agency
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rw�r�xnoa�ga
E xaifd�Ba�T@iES�p 1�
i To verify the curren[ s[aNS and expiration da[e for :
'..........................................this..li.ce.ase.,..A.l.e as.e..vis.it.........................................;
htto'//mvlicense in.qov/eVerifica[ion
• If you ordered and paid for a blue card stock wallet card and certificate, it will be mailed on
the next business day. If you completed this process correctly, your fees will show under
"TOTAL FEE".
• If you selected Free Certificate Printout, the amount under "TOTAL FEE" will be $0.00.
• If your total shows $0.00 and you want to be mailed a biue card stock certificate and wallet
card, click the Licensing Home Page link below to return and restart the process.
Payment received - thank you.
Licensee: Mia K. ]ones
License Number: MT21003453
Mips://mqlicense.in.gaJeGo�lPayrrenlResulLasp�C?ansHer=processed8payment_id=08credit_ca�d_nurtY�er=&license_id=14499028process=DUP&pa�rterrt bal... 1/2