HomeMy WebLinkAbout07040032 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
,> ~'l. OF CAkA_
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3175712444phone
3175712499 fax
www.canne1.in.gov
APPLICATION. MASSAGE THERAPIST PERMIT. $20.00
~ORIGINAL PERMiT
o RENEWAL
1. APPLICANT INFORMATION
a. la~n?m~ J ~
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first name
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middle name
b. \.tg03 k'.nr;,,-CJ
home address
LAv"Me.1
city
IN
state
'I-~O 33
zip code
c.
317-S7,::>--IOZQ
home phone no.
~ 17 -2. q 'f -';-1 bb
alternative phone no.
hIO~(/J.tii-'V;vJy'-'((.CD ""
emait dress
d.
supervisor (if applicable)
:3 I 7 -S 7 S - I 0 2.. q
business phone n~.
business name
state
'+(0033
zip code
e.
4g0~ /(ur;,^-C~.
business address
LCLIf\'VI.e..1
city
IN
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO KYES
b. Have you, within the past three (3) years been convicted, or plead Nolo Contendere for any crime of
unlawful deviate conduct, deviate sexuai conduct or sexuai conduct as defined in Title'jS'o{(lie...
Indiana Code. If yes, explain below. /,., > .:~....,~..:.,~(:~\~
':li;{No 0 YES Date I Location I Offense ! E-/ ~ ';:,. '--: "::. \
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c. Have you, within the past three (3) years, had your massage therapist's Iicense'or.permjt'deiiled'c ,
or revoked for cause by any governmental entity in the United States? If yes, explain. below..
JirNo 0 YES
Date J Location J 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;
o 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,
o NO ,tl(YES name of school I institution lV1ot~(l","- Col\c::..j~f ZoJ.~ !,.J\H-k.
MOeA..:t.1 :.H~5
b, I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o 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.
o NO
~YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a,~ /v\",,,,,a('nu~~d- C().'lmd I I tV
year ~ business name city, state'
57:;-\02-'1
phone no.
b.],L VI
year occupation
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c,_
year occupation
~
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business name
city. state
phone no.
\,l
ill
business name
city, state
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
~ NO
DYES
- .
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,'State~.dtJndi;ria>o) ,
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-;::-atteet tnat.all of:the:above information is true and correct to the best of my knowledge and belief, ( understand
,0~t.any ma,teriaiiy false, misleading, or incomplete statement on this Application shall constitute grounds for
'crjenial of.thisappliciition and/or revocation of my Massage Therapist Permit.
~:~nt;;~p~- ~ ~
HODDE BROWN-SCHUSTER
NOTARY PUBUC STATE OFINDJANA
MADISON COUNTY
MYCOMMlSSION EXP, IULY24,2010
20~?
, -
Subscribed and Sworn to before me this
My commission expires on
,20