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Home My WebLink About14050031 Application G`,t.lOF�CAI��L s � Clt of Ca el � . � Y — Department of Community'Services 1 Civic Square,Carmel, Indiana 46032 IN�IAN� (317)571-2444 phone (319J 57L-2499 faz www.cartnel.in:gov i APPLICATION - MASSAGE THERAPIST PERMIT - $20.00 �ORIGINALPERMIT ❑ RENEWAL y"D�6� 3 1. APPLICANT INFORMATION a. ��l�i�l�C�/'1 , � �/��/� �� I �' last name first name middle r� e b. ��1 � s L �-f-f� �(�}�t C��c��o ��i S��oa3 y home address city state zip code c. � I 1 " _7 �' "S��- I /"�r�'l �S�'� �C✓n/h,I� �'1 home phone no. � altemative phone no. �e ail address d. , - �� l'�>r�� l,h�z 3i� -� �I-ssa l business n me supervisor(if applicable) business phone no�. e. �clt�U �". � ��"' S�. Svi�2 �0 � (l>( Y/vl.f � °�l y�P�S„� business address ciry � state zip code � � l� L� � �� 2. APPLICANT BACKGROUND INFORMATION D a. I am eighteen years of age or older. ❑ NO �YES MAY 0 5 2014 b. Have you, within the past three (3) years been convicted, or plead Nol Contendere for any crime f unlawful deviate conduct, deviate sexual conduct or sexual conduct a �f=�P� �n Title 35 of the Indiana Code. If yes, explain below. f�NO ❑ YES Date I Location/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/Location/Reason ' .•11 •' ;. � ''M1.. i � � � � � d. Attached is,a copy of my Limited Criminal History report, which was:providedto„me by;the•Indiana � State Police no more than thirty(30)days prior to the date on which:l am•submitting thistapplication to the Cityof Carmel; , ,. ._ . � NO O YES 3. MY QUALIFICATIONS: a. I am a graduate of a school or institution of massage therapy wfiich 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 � YES Name of school/institution V�/(�� 71�` �f .p-l(�S.x�� ✓� �� 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 agg�egate. ❑ NO � YES 4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS. a '� I� �a � Z M�',S�a�,t �'�V✓r�e,� � �o3a- 3��-77/-n�-I year occupation busiqe,�s rt�J�Ip� city,state zip phone no. �� - J b. year occupation business name city,state zip phone no. C. year occupation business name ciry,state zip phone no. 5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE I have received a corriplete copy of Carmel City Code Section 4-21 ❑ NO �l YES State of lndiana ) ) SS: County of Hamilton) 1 attest thatall of the above information is true and correcf to the best of my knowledge and belief. I 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 Rermit. °� //l�lCr'r �-�GI�S�l-� Signat Appiic�ant 'J Name mtetl Subscribed and Sworn to before me this�day of � , 20� �s+ PAMELA K. LUX � l/� � S� � County of Res: Hamilton � � o My Comm.Expires 4-25-2015 Signature of Notary Comm. No.564882 �t l� � /-- L � �/ I � I �/ 1 /-1 �_ t- �._�t/� Name Printed My commission expires on y -a 5 , zo� /elcometo Indlana Licensing — S/5/14 8 25 AM I —_ s ... . '7: _ ' 'L =y F. vq.'�s �� r � � _ ..!. . � - .. f p° , �, _ . - '"= 3' �: �t r � `: [ � �' � _ �. .-._: � z3r° s'P� i � .I `T. �+-_,- -'f .—�_ � � • � ��J �.� �� T�� Oniine Licensing � ° � I r �.s.�. _ ,� ��-- -�s� - Payment Receipt If you paid for a certificate, it will be mailed on the next business day. You may use the certificate i below as a temporary until your order arcives. i If you selected the Free Certificate Printout, print and cut out the certificate below. .................................................................................................................................................................................... 4 a� � Indiana Rrofessional Licensing Agency ' �•--> +� 402 W. Washington Street, Room W072 M y � �, Indianapolis, IN 4620d �aie MT212042$5 Megan Garrison has completed all requirements for licensure in Indiana as a MAS3��a�1f1E1�PIST To check the curre�t status and e�C�� date for this license, please visit htt�•//mvlicense in a v/eVerification i Michael R. Pence Nicholas W. Rhoad ' Governor Executive Director ; ......:...................................................................................:............................................................................................. . .. .. .. . ............................................................. State of Indiana Professional Licensing Agency ...........................................................................:............................................................. i �✓�� i �� Indiane Professional Licensing Agency , �,��`, � `..�:� N��r32�i-�i�5n ' ex q�F�'9RC#��I�k�'�i� �i To verify[he curtentstatus and expiration date for this : :...liaerase,..please-uisit.http�<lmvlice�se..ir�aou/eU.ecificatiox�...; • If you ordered and paid for a blue card stock wallet card and certificate, it will be mailed orr 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. e If your total shows $0.00 and you want to be mailed a blue card stock certificate and wallet card, click the Licensing Home Page link below to return and restart the process. https:l/myiicense.in.govlegov/'vaymentResulc.aspx?answer=processed&...dit_card_number=dlicense_id=15�7405&process=D�P&payment_balan<e=0 Page l of 2