HomeMy WebLinkAbout07040036 Application
flf 67010()3{P
City of Carmel
,
.. OFCA
. <c;"~'i ,i. ~~~
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
l1\rDlA~~
317571 2444 phone
3175712499 fax
www.canneLin.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
~RIGINAL PERMIT 0 RENEWAL %0(07 ~ ~
N..Q- ,'~
1. APPLICANT INFORMATION
a.
I .
+tP\R-9~K
last name
\;"\tzUAN \ S
~\.JN~
middle name
first name
b.
\~\ 'l.'=t ~hc"oU\,","\)<<-
home address
IJ0 8:>~\ \2:LD
city
l\U
state
c.
S \'1 g[ 'S9L~\
home phone no.
alternative phone no.
. .' \ ,\
~",,'Z~c.\.'\'I2"'-' C'i"\\ (9 (,""\'1.u:J
am ail address . C..L-r, \
d.
c....-:T" \" \""\ . L LC
supervisor (if applicable)
:::, i"+ Co '2..L, '2~ S 1
business phone no.
business name
e. r~:;2ci'S \ \\'~b~ S Sic- Sk\\'b c..=--\-,~
business address city
state
~loG'~'Z
zip code
\W
2. APPLICANT BACKGROUND INFORMATION
a.
I am eighteen years of age or oider.
o NO
~ES
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.
~ 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, expiain below.
/
~O 0 YES Date f Location f 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;
DNO ~
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
~YES
b.
name of school I institution \ \A"\ v. .~ '^ C ,,;\,,=~ ,~~d-.u""",-A
~='~'~"-.l" ~ i.Y 800 ,^'i'\O
I have attached 13 copy of my diploma or certificate of graduation from an accredited school or
institution of massage
-../ --h".. .. . . !\
o NO '\:J 'YES . ''--''-''v~
c.
I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
~S
o
NO
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. '2;(, '-1,:c<Yn'ci\l.,-<~,"& c:\\-=>M. LLC, c.~
year occupation business name city, state
"2:> l'1-b2.l,'2. 1- S \
phone no.
'b"S --, I
b. _ tlc"""",';$ ('-'<1''-''
year occupation
"-Q\c,-",~ \:\o...\-~-
business name
c.c-,-,,,~\
S ltb2.b 73'2J\
phone no.
city, state
c. ?L,. \1o.no"',r;C~~
year occupation
\-\c. \C'-"~~ \\C'~W::>JU-
business name '\
c.~~~
?'l-::t-61b2t'S\
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
.g/YES
State of Indiana )
) SSe
County of Hamilton)
I attest that ail of the above information is true and correct to the best of my knowledge and belief. I understand
that any materiaily false, misieading, or incomplete statement on this Application shail constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
", i fib
ubscribed and Sw rn to before me this day of
,20