HomeMy WebLinkAbout14060037 Application �
G�,�.� oF�AR,��� 0 � I yo6 0 03�
. Clt of Ca el
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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