HomeMy WebLinkAbout07040093 Application
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317 571 2444 phone
3175712499 fax
www.carmeLin.gov
APPLlC"ATION - MASSAGE THERAPIST PERMIT - $20.00
J ORIGINAL PERMIT 0 RENEWAL
1, APPLICANT INFORMATION
a. IJi\ ,0 V\e if'
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first name
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...., middle name
b.
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home adoress city
('\17 ) t45-5S~o MIA
home phone no. alternative phone no.
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state
Li GJsiI
zip code
c.
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emall a dress
e.
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city
CJ /7 ) c:; C/1- - ~95f'
business phone no.
--rill LI (;03 ).
state zip code
d.
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business address
Cha I' 1,'(1 Mars~
supelVisor (if applicable)
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2.
APPLICANT BACKGROUND INFORMATION U) F 1I W dl1b I! \ \ i
a. I am eighteen years of age or older. 0 NO fa"'Y'ES ~ I APR 1 2 2007, . '
b. Have you, within the past three (3) years been convicted, or plead J,I~ Contendere for any crimJ
unlawful deviate conduct, deviate sexual conduct or sexual condu t as defined in Title 35 of the
I~di:;pa Code. If yes, explain below.
tr'NO 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 ~voked for cause by any governmental entity in the United States? If yes, explain below.
ri NO 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 <f'rmel;
o NO 'D/ 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 at least five hundred (500) hours of supervised
instruction before I was awarded my diploma or certificate of graduation.
D NO .~ YES Name of school /institution --W:tf ICi l/1 Lo!! -f';t c._
b.
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of mass~e
D NO w./YES
c.
I have attached proof of my professionalliabilily insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
~YES
D
NO
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a I:Jl l--Qq eLf: ( U g,S TflJI0V1i1 rt1/15 ,7J.I!~
year occupation busin 55 name city, state zip / phone no.
b.~ 5elr,\f(~,(~M(:
year occupation
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business name
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city, stat~ zip I
phone no.
c.~
year
0551\!-u h I rt'If_M.e II p r
occupation businesS name
(,110"-' fepf1if rY\d-/h~(!;"S ,~f-/!df/
, city, state zi I phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
D NO
~ES
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.
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Signature vof Applicant -r I Name pnnted, ( I
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My commission expires on
,20