HomeMy WebLinkAbout07040033 Application
;
. .~'i OF CA~
".... ~ ~~
..
7, it () 7 tJ~/ DO 33
City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
11\TDIAt-'~
317 571 2444 phone
3175712499 fax
www.cannel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
,:tORIGINAL PERMIT
D RENEWAL
1. APPLICANT INFORMATION
a.
.<, . \.
: )\!\,- , ~'-
last name
, \i.z. '\ -e. \J\. e_
first name
~,,,,\L\ 'C:.-
middle name
b. :") \ :5 3 ~ C::\eu....( u.YL1,ty
home address t
\ N1:Jp\ S
IN
'-\ ~ d..2,"I
zip code
state
c.
~\l- \~'b -\ ~~ ~
home phone no.
alternative phone no.
smail address
d. '{"j\(\<2-('\cx-IL'S \.\ f\ \ Q. <'.. 0, I'-.:l \ 'f'r
business name supervisor (if applicable)
'.:c,\"t- '61.\'is-(\~"2.1
business phone no.
e. dCOO i:.\\~'\-c....S'\- g.. L-\
business address city
~ p..Q...V\^-Q ~
11\..\
state
'--\ Lc. 0 2'> ""2-
zip code
2. APPLICANT BACKGROUND INFORMATION
a. i am eighteen years of age or older. 0 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,
tlNo 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.
~O DYES
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 applicatiQn to
the City of Carmel; .
D NO p. 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 alleast five hundred (500) hours of supervised
instruction before I was awarded my diploma or certificate of graduation.
o NO \lI YES name of school I institution .1: tJi); An 14 :bu fb,'/1e,sC of ( (j)~ (1
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o NO
!p- 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.( !'/IY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a.;.,)Dol. tn-r/8iJI4uv c<;hevl()~jL<:' C-f1IUrtd
year occlipation business name city, state
/A.)
8'-(1 ''732-/
phone no.
bJr;<tY-O~ 'Ole-bu 1M l'
year occupation'
~o..\f\D. ALl...
business name
c:.. f'-.~ \M-<2. \
city, state
IN
~<..\l\ -1..0313
phone no.
year occupation
city, state
phone no.
c.
business name
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21 ~O
DYES
State of Indiana )
) SS:
Counfy of Hamilton)
I altest fhat all of the above information is frue and correct to the best of my knowledge and belief. I understand
that any materially false, misleading, or incomplete statement on this Application shall constilute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
dJfutL ~/iJ
Signalure of Applicant 1-1 Ell e IV II Sfr({ Tie-51-
Subscribed and Sworn to before me this ~ / day of 11 avc.h ,20!1!l
otary
y A. Wedd'-n
My commission expires on
,20_