HomeMy WebLinkAbout14050018 Application G��� � � A��l •
m . . » - � �� of Ca � el
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Department of Community Services 1 Civic Square, Carmel, Indiana 46032
�NDIAL�P (317)57L-2444phone (3�17)5714499�fax www.carmel.Pn.gov ��(�.�OQ ��""
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
❑ ORIGINAL PERMIT ❑ RENEWAL
1. APPLICANT INFORMATION
a. /S(1�/�L� , ��Nk �lV C�
last name frst name middle name
b. /32,� S , %.�/IIZo/t/' � /�Dl-C�/�0 7/c/ �6`QaZ
home address city state zip code
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�tZ, 2�� ��c� � � � � � � �
home phone no. alternati I oneno. email address
MAY 0 2 2014
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d. ov � �,� �SS�.
b sine� supervi ��if aoplicable) business phone no.
e. l��G • S . Gk1 �` P � CCc(''i�1� � �v
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/Location I 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 Date I Location/Reason
d. Attached is a copy`of my Limited Criminal History report, which was pFovided to me by the Indiana
State Police no more than tfiirty(30) days prior to;tlie.date'en,which l am submitting this application to
the City.of Carmel; -- �
❑ NO ❑ YES -
3. MY GIUALIFICATIONS:
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 otherthan
, 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 ❑ 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 liatiility 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 , ciry,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) �
1 attest that al1 of the above information is true and correct to the best of my know/edge 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.
�� x'�"`� vn��� m r X_
SignaNre of Applicant Name printed
Subscribed and Sworn to before me fhis�day of /�(G�/ , 20�
�
- � -� ' ��- �.
- _ .. �� Signature of Notaryr
-- . -= _ /3ob6�` Jo ��� �i,�
. . . : - Name Printed
- _ - �_ My commission expires on � -2 , 20 �C�