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Home My WebLink About14050067 Application I! G.z� °�Aa`'TFr . � . C �t of Ca e1 . � Y ��w� Department of Community Services 1 Civic Square,Carmel, Indiana 46032 �'DIAlJp` (3 1 71 5 7 1-2444.pho�e (317)57I-2499 fax www.carmel.in.gov APPLICATION - MASSAGE THERAPIST PERMIT - $20.50 LL7 ORIGINAL PERMIT ❑ RENEWAL � �S�O �p� 1. APPLICANT INFORMATION a. I-�ernev� , SU � 0. 11 FR2RGeS last name first name middle name b. S`} leo hoor� (�D , Znc\ ,��v.n�oi.S � �l �1-lQ a."�Yi home address � cHy state ap code �. 3�� 293-'�t�ol goa,�fla�nce�HOl.�on home Dhone no. al�emative phone no. email address d. �� 05 `� ltldnrc. RnFl04x:°`�CITt'�. 3i�-- �-��% -�{ 44�i • business name supervisor('rf appiicable) - business phone no. e. ��S 711 i N01 S S�"• C.c✓�Jr.�� i (1 1�-�u G,��, business address � city state zip code .S�:.OZ. �O 2. APPLICANT BACKGROUND INFORMATION a. I am eighteen.years of age�or older. ❑ NO �YES b. Have you,within the pastthree (3)years been convicted,or plead Nolo Contendere for any crime of unlawful deviate conduct, deviate;sexual conduct or,sexual conduct as defned in Title 35 of the Indiana Code. If yes, explain below. L�'J NO ❑ YES Date/Location/Offense c. Have you,�within the past#hree�(3)years„had�your'�massage therapisYs license or permit denied or revoked'forcause by�any governmental entityinlhe�United States9 If yes�, explain below. �27 NO ❑ YES pate/LOCationlReason d. Attached'is a copy of my�Limited-Criminal History report,which was provided to.me by the Intliana State Police'no more than thirty(30)days prior to the date on which I am submitting'this application to � the Cityof:Carmel; ❑ NO ❑ YES � � , I� 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 Etlucation-ot similarstate agency or commission of a state other than Indiana thatrequiretl my successful completion of at leas6five hundred(500) hours of supervised instruction�before I was awarded my diploma or certificate of graduation. ❑ NO UO YES Name of school/instiWtion .J...l� P U 1 S IlC� �D-*��M�JG��S T b. I have attached a copy of my diploma or certficate 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 l� YES 4. MY EMPLOYMENT HISTORY FOR PAST THREE(3)YEARS. �cDS-ac�y . 3i� - a. hqsSnu+w..wn�e+ 01 09� no�n+h CFlr.rtJLR.. ,su 4�03�, �-G(,�' 44�IS� year occupatbn business name city,state�zip phone no. IL.0- 2�4 - �oi3 , b. T1RSSq�i�u+�p,i�' O l0 9y wES� AJOYI 3 �il year occupation business name city,state zip phone no. c. year occupation business name city,state zip phone no. 5. RECEIPT OF MASSAGE THERAPISTPERMIT ORDINANCE � J- `�d�'`'��`=�� } I have received a complete copy of Carmel City Code Section 421 ❑ NO �YES State of Indiana ) ) SS: Counry of Hamilton) � i.d;attest that a/l of theaatiove mformation is true,;and correct foYhe best of.my,knowledge and belief.,I understand . .. .. .. . . _.. ., .. . Yhat any matenalty talse; misleading, o�incomplete statemenf on this Application shal/consfitufe grounds for denial of this application.and/or revocation of iny Massage Therapist Permit. �u��, F - I�c�N�-c.> S Js a n F . \a c�-c�c�c�` SignaWre of Applicant Natre printed ``a y �� !� �/ Subscribed and Swom to before me this � da of `� , 20�7 � �OFFlCIAL SEAL CRAIG A.SCHOLTES ��^�: NOTARYPUBLIC-INDIANA Si atu�eofNotary Y HAMILT�N CGUNTY /J��/� n, � i� /�� '�� °` M Comm:Ex ires Mac 2,2076 � � N � Name Printed / My commission expires on ��- 2- , 20��b �`� Ss��° t" H. � � �t� A ti ... � n . ^J,�S.' �p : . .�..� . . � � r.{;,,- Onlirie Licensin� � > �`�°��' � �� ,',: �• �.��.� �< � ,.�sti��,.�vs� Payinent �eceipt 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 Cartificate"Printout, print and at out the certificate below. faM� �'�aTp�� /`�� ,x Indiana.Professional Licensing Agency ��1a4 ('�ir „ ��I'�ti# dD2 W. Washington Street, Room V1/072 �' '.,�'�'��r3°� Indianapalis, IN 4620d a,• ;.,+ ... .:.. �..„'?e%a,,.,• Susan Prances Herner MT20900418 has compl2ted all requi�ements for licensure in Indiana as a MASSAGE THERAPIST Expiring May 15, 2017 To checkthe currentsCatus and expiration date for this license, please visit fittp://myAcense.i n.gov/eVerificatio n Virgil R. Madden Executive Director Indiana Professional Licensing Agency _..................................................................................._...,......_............................_..._..._..,.._......._......._........._............................,.,.............._.................._....._....._...._............_: ..... . . ............. . ... .. ........ .. . .......... _...._.... ;�'$�ij. Indiane�Pr`ofessi6nsl�Licensiog,Agency '� Susan Frances Herner MASSAGE THERAPIST MT20900418 Expiration Date: 5/15/2017 ` To verify the current.status and expira[ion date for[his : � ; license; p�ease visit htto://mvlicense.in�.qov/eVetification ; https://mylicense.in.gov/egov/PaymentResult.aspx?answei=processed&payment_id=0&cr... 3/26/2013 " �� i� '17 `! � �s :: � a � � � e A " -. 3 p � � b � z o T � �+ o o �� .7. �n :. ac � w �l n N �N 0. n Lt fD tJ� � .� N �. � � `^r G A y tl4 � '.�.i o � � � `-° a N � O � �y �. .A�i �� -� N � a � � � a 0 0 �' a� W M'C " CD � u Ti ry ?' "�' .-t a � /V (�"o t�o P- �. l 1 � p Q7 0. � � /'•' n �. b � � - r�vy�.�� o° �. � a 'qj � � z��,��. ;�' �� o�a �7 � `� .�. e'µ� � M � � \\ � .� N � / � � � 6 � � � \ � � � 0 � '� 9 �. p�',�., `n . � � � � , � ��. w � o .r«� ,� � cu �. �� C/1 � , � , _ p � a � ,�. rn �� R. � � � ` �",.F;, " rr , � �. � �d � ry � ^ � �\`��,,, � � u � ey4 � � � � � / T � ` J ��3 \ � � �� K M� '� 0 � � � � � � � .b R �,� ��y \ .� N n,�Dp. �' -a, ^ �� y� f l�D �� n v�i '\..� '.V N o, ac w � � � ° � � �] � � � b z � m w -e C� .'i' `p• � O' . � /� /�� m �,y� cn � �. a J �' � � m � � !� _'. �' � o � b � � � / � O � w �._, � ' �, �'!�% p�a m° : � � f✓ � ^ �� .. -' Rf � �� . _ �; � � :�%��"' j � a fi � '� Y w � w �• �' C � C <� � � � CD /�y� C � � � � �. l�V � O- � n � O � `� ro � �p� � � � ' 2 ,�' `C .� (�D !ii n �y =i .0 C" Gj„ N � � � ld .p�j � /� K � UQ .�i� � � � \v � Mqy � g cn ]. C �- p� � �j "� PC s a �Q <� .`�� \ � � � � n -�+ �. O � G, � O � � � � � /� � � O � � � � � a �O � r 0. '� � � C C►� v w � � o � � � � � � � � � � � � � _ � pa. .� - � fi+ , t �' ::,. ` = c �,� 4 3 x � « ', �' `d�mp^}�Asso�aled Bodpyork 8 M'ossage Professiondls R �� r , = K4 i a`j �' ��SF �� t J t 4� �; �`� - X i i 2";2irura6mmm , "'� 800.45811d7� �-.T ::�ay 751�Gene�`1�p,�,5ui¢�IO,Golde�ol�804UI`e; Nnme: Susan Herncr � . � .. ... - Level:Cenified(qCMT) In#:825904 � ' Aaive: b/20/2p03 ; Expire: 3/30/20J i � '�. TN�S CARD 4ERIFlES IdEM6ER$HIF yy�7q qBMP C06IIdOtd2TY LEARNING NETWOAIC INDIANA UNiVERSITY POADUE UNIVSRSII'Y INDIANkPULIS CGNTINUING STUDIGS ' - 620 UNIOfd DftIVF., SIII'iE 'd=2 � INDIANAYOLIS, IN 952G2 37�7�-27B-750� TRANSCAIPT 4;0/2069 Rti:?STRAN'P: Susan F Aerner [XNO-s3-A36E) £�SSL Crown Point. kd Indianapollis, SN A6279 F:tanber COUrse Name 3rade CS[7S Hnusrs C22�I1;'A00 500 1�3our 'i'herap�utic Ffassaye � '�� 2/�18/2003 throu<jh 12/6/2003 022I99�17 T}i�:.�,pevtic ciassagA 41int_er 2003 Applicarion � � throign 0�3�_13�3�'+' lontinl:iP.9 EC4VCdtiOrl fo2 S3dsSdQ�- TheTe3yiGC5-EthiCS �.� '� 2!1/2005 Y.hrough �2/1R/2005 G42I9cA72 Contirm:n9 Education'for Massage Therapists: Advar. 1.2 12 1/30/2005 througkt ?,/lfl/2005 u54I21riU0 New! �iJOman'S �Advanced Massage Issues � � 9/1;/2005 through 1.0/ll/2005 TOTaL: 1.6 516 T Grades: A cxeellent / B Good / C Avera9e / D Poor / F Pail i p Pass . a