HomeMy WebLinkAbout14050017 Application c`�,� o .�`'R'�'�,c .
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— Department of Community SerJices 1 CivicSquare, Carmel, Indiana 46032
IN�jAN�' (317)571-2444phone (317)��71-2499.t'ax www.carmel.iagov ��QSOQ��
APPLICATION - IVIASSAGE THERAPIST PERMIT - $20.00
❑ ORIGINAL PERMIT ❑ RENEWAL
1. APPLICANT INFORMATION
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a. �,�j.0 , �, 1 �7�
lastname frst name middle name
b. ��1� 13z.ULC�IIZ � /�7�1�� 5 /�✓ �
home address city state zip code
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home phone no. alterna hone no. email address
MAY 0 2 2014
a. ��-� }=i n e SSC�
business name supe sor(if applicable) business phone no.
BY
e. l�l� .� . R�tr�C�i�' l� ����'ar+C? � - 1/� �J�O�i2
business address city state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ❑ NO l� 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 therapisYs license or permit denied
or revoked for cause by any governmental entity in the United States? If yes, explain below.
�NO ❑ YES Date I Location�Reason
- ,•�c n�p[! I.,
d. Attached is a copy of my Limited Criminal History report, which was provided,to;me by the Indiana
State Pollce no more than thirty(30) days prior to the date on which°I='amfsubmitting this application to
the City of Carmel; '"--"� m�'; "` ';
t•yc Y��GY.-.,
❑ 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
inst�uction before I was awarded my diploma or certificate of graduation.
❑ NO ❑ 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
❑ NO ❑ 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 ❑ YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3)YEARS.
a.
year occupation . business 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 complete copy of Carmel Ciry Code Section 4-21 ❑ NO � YES
State of Indiana )
) SS:
County of Nercdke�
M��.J
1 attest that all of the above information is true and correct to the best of my knowledge and belief. 1 understand
that any materially false, misleading, or incomplete statement on this Application shall constitute grounds for
denial of this application and/o�revocation of my Massage Therapist Permit.
���-�--�� �� Bo .Z�o
Signature of App�� Nameprinted
Subscribed and Swom to before me this .%C./ day of /1 � , 20 ��
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. Ji``� v IMRiquCOUHTr � Si nature ofNotary
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� Name Printed �
My commission expires on�-�� �- , 2p �'S
Welcome to Indiana Licensing Page 1 of 2
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- Online Licensing
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 certifitate below.
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;-a, � Indiana Professiona� Licensing Agency
�:;a �' 402 W. Washington Sireet, Room UV072
'•_! �i., Indianapolis. IN 16204
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Libo Luo '
MT21304787
has completed all requirements for licensure in Indiana as a
MASSAGETHERAPIST
Expiring
May 15, 2017
To check the current status and expira[ion date for this license, please visit
http://mylicense.in.qov/eVerification
Michael R. Pence Nicholas W. Rhoad
Governor Executive Director
State of Indiana Professional Licensing Agency
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' :'•°`��• India�e Protessional Licensing Agency
.� �
v Libo Luo
MASSAGETHERAPIST
MT21304787
Expiration Date: 5/15/2017
i To ve�ify the current status and expiration date for thls ;
� license, please visit htto�//mvlicense in aov/eVeriFlcatlon !,
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