HomeMy WebLinkAbout07040040 Application
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Department of (!;ommunity,Services-1-Cillic'Square, Carmel, Indiana 46032
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3175712444 phobL-_317 57) 242.9 fax J www.carmeLin,gov
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APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
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~ORIGINAL PERMIT
1. APPLICANT INFORMATION
a. BLAzrER. JoliN
last name first name
b. leSOS- /II. DELAWI4Re 5T. ~DI:A.IYAPo L:r:S'
home address city
c. 3/7 -$'4.f- 47 ,0
hor:ne phone no. alternative phone no.
pA::r./'J RELJ:IEI~
d. /VIA <:SA,6.F -n+6IZAPY
business name supelVisor (if applicable)
'-40 S. RAN6-c.L-S:/'JE RR
e. 511J:.TE it? CAR/l1 f. L
business address city
t:/)wA~])
middle name
:r:/'I LJi,).,f'o
state zip code
BLA7-J:Ellloli t:f}J
V A'~J+"o. C'. ,,/1.1
smail address
3 J7-!1L1i'- 4zso
business phone no.
::rN, 1/6032-
state zip code
.
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO IlYYES
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 0 YES
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.
.
~o 0 YES
Date I 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;
o NO ~ES
.
.
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 tha'n
Indiana that required my successful compietion of at least five hundred (500) hours of supervised
instruction before i was awarded my diploma or certificate of graduation.
D NO ' C9"" YES
nameofschool/institution AqUAR:xAi'l t:lr>E: AL,ERNAT-rvI=5
b. I have attached a copy of my diploma or certificate of graduation from an accredited schooi or
institution of massage
D 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.
D NO ~YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
f"\AHA{,-E pA"3:;.I Rf./.:::r;(;F
a. ').00" ',l-leIl.An,r HYl A ,,^t:..f T/,+'~A1'1 t'ARfI1E.L 'TAl
year occupation business name city, state I
317_'ii'4f-'i75b
phone no.
MMfA6-f
b. ").005 '7"H€2AP:;:-jr
year occupation
pl't:r~ R. E.LI:. '= F
fYI AH AC-F 'THeRAPy c.A~IVII;.L r/'J.
business name city, state I
317-f'lf'/.t 750
phone no.
c. ?oDO~
year
yvIMfA~t
me(lj\ (13:5'1'
occupation
PAIN I< EU:E 1=
MI't(lAC-P -r~ef<.A'P,/
business name
CAl:'r>1t=J IN.
city, state I
3 J7_1'If-l.J7Sb
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I
i have received a complete copy of Carmel City Code Section 4-21
,
D NO
ar" YES
State of Indiana )
) SS:
County of Hamiiton)
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 revocation of my Massage Therapist Permit.
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Signature Applicant
Subscribed and Sworn to before me this
qtJ:>day of
,200
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My commission expires on hfi. ;Z 0, 20M