HomeMy WebLinkAbout14040246 Application G��Y o � A��'1 •
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— Department of Community Services 1 Civic Square;Carmel, Indiana 46032
1N��A��' (3U)571-2444.phone (317)-571-2499�fax www.carmeLiagov � �� ��Y�
APPLICATION - � MASS�4GE THERAPIST PERMIT - $20.00
ORIGINAL PERMIT ❑ RENEWAL
1. APPLICANT INFORMATION
a. lil\�1S�1GV�SC�1 � ���'1 \'� l-UYIV�
last name frst nahie m�me
b. ��� �i'L5�{�WV�� �f. �.'iAnqpo �lf /H �1(��dl.o
home adtlress city � state zip code
� 3n=�1q3- It�SS� � . �n-a�a -��o°� r ��a�ee�:-;rgko��_a3� �1����
home�phone no. altemative phone no. email address
d �V\c�Sau� ��I Sa� Na-�c�„\�� �e�n2, 3i�- �13-39 oq
business na� supervisor(if applicable) business phone no..
e. �l7 UD 1� I OL�" St l A r rv�t,� �� � le(7�j'�
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.
�Q,NO ❑ YES Date/�LocaBonlOffense
/v
c. Have you, witfiin the past three (3) years, had your massage therapisPs license or permitdenied
,or revoked for cause by any governmental entity in the United States7• If yes; explain below.
04 NO ❑I YES i Date/Location I Reason
/V
._...___'_-._-�_____._.__' .' ' '
d. Attached is-a.copy'of:my Limited Criminal History repo�t, whicFi�was'�piovid'ed'to,me by the Indiana
State Police no more ttian tliirty(30) days prior to the date�on-wh�ich'q am�sukimitting this appiication to
the City of Carmel; i ,�,.`' ";'���!�; � ':C` �,. �.
� . � �' .�r�:�:l - .
❑ 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
Instruction before I was awarded my diploma or certificate of graduation.
❑ NO �il YES Name of school/institution �ndiA✓t�l, l3uS i n�ss �o ��'e Q'�–�
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
0 NO � YES
c. I have attac ed proof of my professional liability insurance of not less than $100,00o per occurrence and
$250,000 annual aggregate.
❑ NO � YES
/ �
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
�,f n
a:b9'C°r111� _ �'�4'�W ' MO.SS�I�"ih�4'Sati . lG(W1�� /w `Il�3o? ,3�?`873-3909
year occu a6on busines name city,state zip phoneno.
b. ,
year occupation- ' business name ciry,state zip � phone no.
c. .
year occupation business name city,state zip . phoneno.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21 ❑ NO � YES
/ -
State of Indiana )
) SS:
County of Hamilton) �
I attest that all of the above information is true and-correct to the best of my knowledge and belief. I understand
that any materia/ly false, mis/eading; or incomplete statement on this Application shall constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
1 �FIA�UI. c J}C�huh��. �.hr� S��An$�f ✓l.
Sig�irdtur of Applican� .Name rinted
Subscrib8d and Sworn to before me this 3� day of �pr, � , 20 ��
-��< <.S. NICHOLAS F.MISHLER ��_'�����
f .,'�`�;�,�� � Coum7rofRes:Hami{ton s�9�ac�reorNO�ary �—
� My Comm.E�ires 02•27-2019
�r. Comm. No.624589 • �jG�,. �45 F, /Lt S� (�
r
Name Printed
My commission expires on �Z Z� , 20�9
^etai[s Page 1 of 1
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'' Onlrne Licensrng
NewSearch Pe�son Information
Li[ivatian Documents Stephanie Lynn Christiartsan�
+ �iyital Certilicatian Adtlress�InformaYioq
Ma55a0eTheraPV BOartl
Indianapolis IN 46226
Litense�inFOrmation
�tcense No: MT20900854
arotess�o�: Massage Therapy
Board
ur.�nse rype: Massage Therapist
obrained ey Grandfathered
metnod:
�ssue Date: 5/22/2009
Expiratlon Date; Sl15/2017
Lioense SUtus: ACIIVe
?revicus Action
Previous Action-None
Related ticenses
No Prerequisite lnformation f
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