HomeMy WebLinkAbout07040096 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmei, Indiana 46032
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. ~<i. OF CA.l4t:
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l1VDlA1'<!'-
317571 2444 phone
317571 2499 fax
www.cannel.iI)..gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20,00
e10RIGINAL PERMIT
o RENEWAL
1. APPLICANT INFORMATION
a. J\ U \-1-1_
last name
b. Ho 'Iz. I S+ S+ \Jf
home address
c. 311 ~4{p SOlo 0
home phone no.
d. ~~u~e~C~\1~5~UL~
bus ness name .
:je(""i'SCl
first name
IV\{(( I ~
middle name
Ccv (VI .e\
city
110
state
-3{o03L
zip code
3\1 "72.l :?435
alternative phone no.
-ten?sa}yz~6c.q\obal.
email address r"\e-\-
supervisor (it applicable)
3 n 721 '6~3S
business phone no.
e.
[033 3\'<\ IIY~ SvJ Sk-110 (lev Md
business address city
ID
state
4: <OO?'"C
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO avYES
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 governmentai entity in the United States? If yes, explain below.
Le"No 0 YES
Date I 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;
D NO arYES
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.
CI NO u;v" YES Name of school I institUtionJ\\~'l.an(k;(l CYl>nc\ ()~ Sc\;,.wkc
l"n-ero..{)e.u-\1c..s
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
CI NO
GY' YES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annuai aggregate.
CI NO [3"'" YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. 1..COlv H~1SSAOe_ \2euJ{11Ui'\(t\1 j\(J Wllc.k (\\ (\,\\e\ J \ U
year oqcupatlon J Lb' ass name ) city I state ZIp
-twL<O- P \ <;;,
b. WW &'LI\U!.
year occupation
-4luD7,L ?'1l'i<4I.hOIoO
phone no.
city I state zip
SCLi'Vl.iL.
phone no.
, S(\.(IluL
business name
:cs{J.....V\'U'-....
c. za...-L\; ,S eL\'\'lX-
year occupation
$c:UV\..L-
business name
St.U,\A...L
city I state zip
<;o...v'I'\....iL..
phone no.
.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
CI NO
llV"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 revocation of my Massage Therapist Permit.
1/1 ctJ Ji;
-TP/-ofl /'1. /-f.(..{ 1ft.
Na1bPrinted
/]'?"dayof ita!
/-;
,20
d Sworn to before me this
I
ame Printed
My commission expires on~' ;2..0 ,2021