HomeMy WebLinkAbout07040035 Application
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City of Carmel
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Department of Community Services 1 Civic Square, Carmel, Indiana 46032
INDlA~~
317571 2444 phone
317571 2499 fax
www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
\A ORIGINAL PERMIT D RENEWAL
1. APPLICANT INFORMATION
a.
Sha.d r\'rL
last name
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first name
ke.nQ'e
middle name
b.
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home address
Carf\\>JJ
city
I
4~~7 I
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SIMA,:c.k @.~$enli!- l'\QT
email address
state
It-l
c.
''')\1, SC31, IS\S-
home phone no.
alternative phone no.
d.
~hl,,-;;('lf' ~tr\(l1\\'St
business name
supervisor (if applicable)
'Z,.,iS'61.15'1S"'
business phone no.
e.
SCf? l\\d\4:o.\
business address
~*50'1 CW-\..wi]
city
IN
state
4(C)aJ37-
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO t1i 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.
~O DYES
Date I Location 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.
.eO. NO DYES
Date J Location I 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;'
D NO Q YES
I.
1
...
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 IlJiI YES name of school I institution -AlFiarrlr;o. S:t1fdO\S-';..<M.i;~', .'\L<'Olf1'lJkc
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
MI YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a ~7rJ,e.rnD\cJ. N liW>jp~ ,'o..L.,-J (In.... t'\RJ I 1"-\
year ~ busin~1 \ city, state
l.f(c;(S3Z- ?1?f:;3r/~/~
phone no.
b.
year occupation
business name
city, state
phone no.
c.
year occupation
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
o NO
~ YES
State of Indiana )
) SSe
County of Hamilton)
I attest that all of the above information is true and correct to the best of my knowledge and belief. I understand
that any materially false, misleading, or incomplete statement on this Application shall constitute grounds for
denial of this application and/or revocat' n of my Massage Therapist Permit.
Subscribed and Sworn to before me this c7- 7 day of >~
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Signature of Notary _ . . I
My commission expires on 4t($1 ~5
, 20SZ'
Signature of Applicant