HomeMy WebLinkAbout07040095 Application
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~i. OF CA.,
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fNDIAt'l~ 3175712444phone 317 5712499 fax www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
)( ORIGINAL PERMIT D RENEWAL
1. APPLICANT INFORMATION
a. M,:;-g P-1111A-N,S~SA-;J
fast name first name
b. l If 3gLj IIow ;:~});e. C,4;2/11 tEL-
home address city
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home pfone no. all"",at;ve phone-no. - .
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middle name
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state zip code
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email address
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d. ~ name
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supervisor (if applicable)
(3/7)5/'-1- c:JS-3::2..
business phone no.
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business address
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eily
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a. I am eighteen years of age or older. 0 NO Ii YES
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2. APPLICANT BACKGROUND INFORMATION
b. Have you, within the past three (3) years been convicted, or plea Nolo Contendere for any crime of
unlawful deviate conduct, deviate sexual conduct or sexual cond '.in.JJtla
Indiana Code. If yes, explain below.
~o 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.
)A NO 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 application to
the City of Carmel;
o NO 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 fi YES Name of school/institution /<!ALAMA20D (;'TA,Foe.l7tG"flE'AtdNc.-.
l1,e.rs :; c.HtJDI- oF- M4$A-G-E ~ B."iJy WDI? :...
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
D NO
fii YES
c. I have attached proof of my professiomilliability insurance of riot less than $100,000 per ocCurrence and
$250,000 annual aggregate,
D NO 'r' YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
1\iI!'tSSft&E
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year occupation business name city, state zip
317- gl(/-CD!!
phone no.
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year occupation
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business name
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city, state zip phone no.
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c.::lOOS-pfErMr't>r
year occupation
flc. ~-A-W Y/11 C-A
business name
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city, state zip phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a Complete copy of Carmel City Code Section 4-21
D NO
pr:' YES
State of Indiana )
} SS:
County of Hamilton}
I attest that all of the above information is true and correctto the best of my knowledge and belief. I understand
that y materially false, misleading, or incomplete statement on this Application shall constitute grounds for
de I of this application and/or revocation of my Massage Therapist Permit.
, 5USA-N E. J1EMII17A-AJ
,~rin'ed .Aor' I
Subscribed and Sworn to before me this ~ay of 7_1 r' ( . ' 20$
Signature 0'. otary ()
S:,,4;((Y/h /1/, l.vl! (8,( d
(f4ame ltrlnted V
My commission expires on I'10h. ~O ,20 () 1