HomeMy WebLinkAbout14060118 Application G`,�.� oF cA��r •
� Clt of Carmel
y
Department of Community Services t Civic Square, Carmel, Indiana 46032
IN�IAN� (317)571-2444 phone (317)571-2499 fax www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
ORIGINAL PERMIT ❑ RENEWAL ` � O �
1. APPLICANT INFORMATION
a. DI �1� Q �1�. ��� I.� _
last name first name midtlle name
b. 13�3�� ���ec�� �6�-�`w�� -�--r�1 �I�o � 3
home address �� city state zip code
�. N�� � �7- 7��7-�8 0�, ��rya��� sbc Ic�(,
home phone no. altemative phone no. email address ��
d. �� �'�a.�qe C u�p 3�7- ��7- �58
business name supe isor(if applicable) business phone no.
e. �3`d(�� �'tiU�e� �Y �(,�--�e� ��� v� 3
business address / ciry 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.
�IO ❑ YES Date I Locatlon I Offense
c. Have you, within the past three (3) years, had your massage therapist's license or permit denied
or revoked for cause by any governmental entity in the United States? If yes, explain below.
�NO ❑ YES Date/Location/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 prior to the date on which I am submitting this application to
the City of Carmel;
� NO ❑ YES