HomeMy WebLinkAbout14060073 Application Gl,S.; OF�A��t a
� .. Clt of Ca el
,� . . � � Y
� Department of Community Services 1�Civic Square,Carmel, Indiana 46032
INDIAL`�� 3U)571-2444 hone
( p (317)571-2499�fax. www.carmel.in.gov
APPLICATION = MASSAGE 'THERAPIST PERMIT - $20.00
�ORIGINAL PERMIT ❑ RENEWAL '� ���pC�O7
1. APPLICANT INFORMATION
a N5 h S< h , -S< o ��l /��l c h
last name frst name middle name
b ���% [,/ � �1� f� ��i�1 SNy��I l.S �,,� v�Z � �r
home address city state zip code
c. ��� ' �! 3d y0 �h � s�ap���9n��h GvG ��d�"/�(�
home phone no. aiternative phone no.' email address
d. �4s1�s� �''�y 3� 7-Y�3 - 3so �
business na . supervisor�(if applicable) business phone no.
`' , /
e. 7'600 L' �C�� '� S �trMc� � lN �/do 3 �
business address city state zip code
2. APPLICANT BACKGROUN� 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.
�.NO ❑ YES Date/Location/Offense
c. Haveyou, within the past three (3) years, had your massage therapisYs license or permit denied
or revoked for cause by any govemmental entity in the United States? If yes, explain below,
,iw�0 ❑ YES Date/Loca6on I Reason
r'.. , _ _.. .. . . _.__ -_..__._�
I X�i ; .'t:�_��p.'^c �'-"'.::
d. Attached is a copy of my Limited Criminal History report, whichrwas�p�o,yided�to.me by tfie,lndiana
State Police no more than thirty(30)days prior to the date on`which I,am sutimitting�this application to
the City of Carmel; �� ,,,;,:i�� _�. r,i.� �_ `E � . �
�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 ❑ YES Name of school/institution �c�n,�C �✓o� .Shc,oc,� 6d /�Sl/t�.c f�' Y��
b. I have attached acopy 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 aggregate.
❑ NO � YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS. '
a.2o�� i''1s s . `7'lu.r.P�'rY /`/! 1s1s�c LnJf . .����„cl /✓✓ `��3z 3�7��'73-�4' �f
year occupa6 business name city,state zip phone no.
b,Z0�3 G'ilun3c�Jr Prin�c� I'6.•:{.f5 f�r✓. Cad�. /✓1 ��1 .11/✓ �
c
year occupation business name� city,sCate zip phone no.
c. OJ �w�Sd-r<.i��U�'�. N.IQ� �J�4�'-�r�1� S�Of� /�.Jy �� 70 �O . ..
year occupation businessname city,°state zip phone�no.
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)
1 attest that all of the above information is true and correct to the best of my knowledge and belief. 1 understand
thatany materially false, misleading, or incomplete statement on fhis Application shall constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
�G-�� �j�,, - Seo� ��IGr15Ll�
Signature of Applicant Name printed
Subscribed and Swom to before me this I ��y1 day of ��AxMA_ , 20�
�
PAMELA K. LUX `���� ����
s�y � County of Res: Hamilton Signature ofNotary �
My Comm.Enpires 4•25-2015
Comm.No. 564882 '�i��L/� K . ��X
Name Printed
My commission expires on �-� , 20��
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Agency
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versonaf in�ormation:
Name: Scott Allen Hansen
Address: 1131 Darby Lane
Indianapolis, IN�46260
Date of Birth: 10/16/1967
License.Information:
I�VIfI�/C� aiJYGY IIILVJ�GJV�J
License Type: Massage Therapist
Status: Active
Issue Date: 09/15/2009
EYOiration Date: OS/15/2017
Obtained By: Grandfathered
Disciplinary Action: None
Valid as nf: Mne lim 09 10:51:12 AM EDT 701d
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