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HomeMy WebLinkAbout14060037 Application � G�,�.� oF�AR,��� 0 � I yo6 0 03� . Clt of Ca el ; Y �, Departmentpf Community Services 1 Civic Square,Carmel, Indiana 46032 INDIA�� (317)�571-2444phone (3I7)571-2499�faz www.carmel.in.gov APPLICATION - MASSAGE THERAFIST PERMIT - $20.50 ❑ ORIGINAL PERMIT ❑ �RENEWAL 1. APPLICANT INFORMATION a. �°-c�l1J21 � , ���c��ln� �Cc�c�.lhe. last name first oame mitltlle name , 1L(D/ / b. Royz ci�wu� c� ��sh�rs in/ �/6a�3� home address ciry state zip code � (�r�� ys�-9os� , ., ���a u-��a n�,' � home�phone no. alternative phone no: email address d. 1�L0�Y rea �� -:�2 n ffly-�l�p° business name ���supervisor(it applicable) - � busin s phone no. e. ��7�5 /v0/-�l ����1U1/5�'��.�/�Q� �N y�bJa . � usiness address � city state zip code 2. APPLICANT BACKGROUND INFORMATION a. I am eighteen years of age�or oltler. ❑ NO C�I YES b. Have you, within the past three;(3)years'been conyicted, or.plead Nolo Contendere for any crime of unlawFul.deviate conduct, deJiate�sexual conduct or sexual�conduct as defined in Title 35 of the Indiana Code. If.yes, explain�below. . - �NO ❑ YES Date!Location I Offznse c. Have you, within the past three (3)years had your massage;therapisCs:,license or��permif.denied or revoked'for cause�by any govemmental�entity in the,United States�' If yes; explain.below: �NO ❑ YES �ate/Location l�Reason d_ Attached-is��.a copy,of'my Limited�Criminal History report;which was provided to me:by the Indiana State Police no more than thirty(30)days p�iorto the�date�on;which�l-am submitting this appiication to th Cityof�Carmel; �O � YES