HomeMy WebLinkAbout14060079 Application Gl,S.� OF�CA��r o
.. Clt of Ca el
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— Department of Community Seroices t Civic Square, Carmel, Indiana 46032
INDIAN� (3 L�7)571-2444�phone (317)5712499 fax www.carmel.in.gov - _ �
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
❑ ORIGINAL PERMIT ❑ RENEWAL
1. APPLICANT INFORMATION
a, �12�L�n�U. � �vl0 ,�i� �✓lv� �/1 i./lef7"
last name ��, � firstname middle name
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b. �'`/3 I /a���^�� E ����5 s��� �(�Z.�
home address city �state zip code
� _ ���I - 35 a--�
home pFione no. alternative phone no. email address
/
a. !I�SS'�- C l� �,� �iE Ke� ` 573 —3y�9
usiness name supervisor(if applicable) business phone no.
e.
. ' business address city state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ❑ NO '�,V 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
lndia/na Code. If yes, explain below.
L.�NU ❑ YES Date/Location/Offense
c. Have you, within the past three (3) years, fiad your massage therapisYs license or permit denied
or revoked for cause by any governmental entity in the United States? If yes, explain below.
LY NO ❑ YES Date/Location I Reason
• � -- ' ---- .. _.. . - - � i
iSd-ii{. -. ;1. i �. I,
d. Attacfied is a copy of my Limited Criminal History report, which�was proyided.to,me by the,lndiana
State Police no more than thirty(30)days prior to the date on whicFi I am sudmltting this application to
the City of Carmel; � � � ' �
� �.tci'.� :� ._.. ' I
NJNO ❑ YES - --- -- . — .- .. .. _ ._
3. MY QUALIFtCATIONS:
a. I am a graduate of a school or institution ofmassage therapy which is accredited by thie Indiana -- -
Commission of Proprietary Education or similar state agency or commission of a s4ate otherthan
Indiana that required,my successful completion of atleast five hundred (500) hours of supervised
instruction before I was'awarded my'diploma or certificate of graduation.
❑ NO I� YES Name of school/institution ����� ��u,�r�+�SS Cdl<j� .
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
3 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.� ��' .'�"li`<: (� h1w�c�v„2. � 1 T,'��l,a( S ��n !�i(r�) �/D ��` � l U�
year occupation busines� �city,s a�zip phone no. _
b.
year occupation business name city,state zip phone no.
C.
year occupation business name 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)
I attest that all of the above information is true and correctto the best of my knowledge and belief. 1 understand
that any materially fa/se, misleading, or incomplete statement on this Application shall constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
��� � ��-�-�-�,' �� �,`��;�
ignature of Appticant Name printed
Subscribed and Swom to before me this � day of 1�� 20�7
�-'
� JOSLYN S. KASS I . � ��
S� � County of Res: Hamilton �
My Comm, Expires 11-15-2019 s� ��ure or No�ery
i °' Comm. No.630919 ��OS � ��1 S �<C�.S �
Name Printe "
My commission expires on ����SI , 20�
Welcome to Indiana Licensing Page I of 2
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Payment Receipt
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 arcives.
If you selected the Free Certificate Printout, print and cut out the certificate below.
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_.... _....._. .. _.._..... _.... __..
a��?�a
�g/' ' � �� Indiana Professional Licensing Agency
<��'~���"�� 402 W.Washington Street, Roam W072
g '... �' Indianapolis, IN d6204
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ra�e
Ghonita Anntoinette Freeling
; ;
" - MT20902064
has completed all requirements.for licensure in Indiana as a
MASSAGE THERAPIST
_ __. � ._ _ Expiring _. _ _
May 15, 2017
To check the current status and expiration date for this license, please visit
http://mvlicense.i n:qov/eVerification
r•
Michael R. Pence Nicholas W. Rhoad
Governor Executive Director .
State of Indiana Professional Licensing Agency
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......... ....._.. ....._... .. . ......._. ................. ....�..__:.. ... _...____........ . . ......... .......... ........._...................._......._i
......... ......__. ...._..__ ..._.__ ____. _..........
. ! �,�„.. . �
;.,.'����N Indiena PrMessional licensing Agency _; s,
---- ; \+.»..r� � .
�Chonita Anntoinette Freeling
MASSAGETHERAPIST
MT20902064
Expiration Date: 5/15/2017 -
. ! To verify the�current status and�;expiration da[e for this :� _,
' Gcense, please visit htto://mvlicense.in�.qov/eVe�iFication ;~
https://myl icense.in.gov/egov/PaymentResult.aspx?answet—processed&payment_id=0&cre... 5/7/2014