HomeMy WebLinkAbout14050017 Application (2) 3. MY QUALIFICATIONS:
a. I am a graduate of a school or institution of massage therapy which is accredited by the Indiana
Commission of Proprie(ary Education or similar state:agency or commission of a state other than
Indiana that required my successful completion of atleast five hund[ed (500) hours of supervised
ins{�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: r. i
year occupation , business name �� � city,state zip phone no.
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b.
year occupation 1 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 Ca�mel City Code Section 4-21 ❑ NO � YES
State of Indiana )
) SS:
County of�
M��.d
I attest that all of the above infoFination 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/or revocation of my Massage Therapist Permit.
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Signature of�App i t Name pnnted
Subscribed and Sworn to before me this � day of � �• , 20 �L
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� wiwoyCOUryTV j Si nature of Notary
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Pur P�� sP�, ��,
� Name Printed
My commissio� expires on�-�� Z , 2p �'S
G��Y � �CA�E't a
� _ . C �t of Ca el
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Department of Community Services 1 Civic Square, Carmel, Indiana 46032
INDIA�Q' (3��7)j71-244qphone (317)5714499fax www.carmei.in.gov ����QO��
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
❑ ORIGINAL PERMIT ❑ RENEWAL
1. APPLICANT INFORMATION
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a. �,(,U , �. 1 �U
last name frst name midd�e�name
b ���g ]3z.U L�] 1Z 'n /�777�11vJ�'1- 1�U� S /�/ �
home address city state zip code
� �3i7� �46 - 7�� C� � C� O M [�
home phone no, alterna hone no. email address
MAY 0 2 2014
d. `�c�-�- � i n e S�C.�
business name supe sor(if applicable) business phone no.
BY
e. 1�F/6 S . �?�w��l�r� 1� ��x,}-�L � _ ii✓ ��o�2
business address city state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ❑ NO L'�I 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/Loca6on(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.
�NO ❑ YES Dafe/Loca6on/Reason
��3q �� :.4 �: .
d. Attached is a copy of my Limited Criminal History report, wliich was prowd`ed�to:me;by;the lndiana
State Police no more than thirty(30) days prior to the date on whichtl'am�'snubmitti\g fhis application to
the City of Carmel; _ �_�,...��.,,.
❑ NO ❑ YES