HomeMy WebLinkAbout07040081 Application
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C[~~~"IILCarmel
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Departme~t of Community Services 1 Civic Square, Carmel, Indiana 46032
317 571 2~4 phone ---TIB7f2499'faxJ www.carmel,in.gov
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INDIAt'<~
APPLlC~ION - MASSAGE THERAPIST PERMIT - $20.00
~RIGINAL PERMIT CJ RENEWAL
1. APPLICANT INFORMATION
a,~C: i-f J-I-I1Rf
last name
C4/2.o L-
first name
b,
Irtolp/~
c,
2 3 SO/A-j-t,,- 'DotvlU1 ,AV'C
home address city I
(ili)q1~-Ob67
alternative phone no.
e~~2~fJ -Q'7'n
d, ~R.. "uUR.nafi'Dh.
busine name
e,
/Jjt; fi1P);uLC\f Si,lif E-6-
business address city
S"" VI. e
middle name
rrJ
%2/9
state
zip code
I<R.. j /) ilR Yl,,:htJn P/),1 .s.
e\1lail address ~c8/olaq i.
(~r;) O,7<:)-Oh67
business phone no.
..j:tJ L/~D3).
state
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older, 0 NO
~S
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, explain beiow.
~O 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 Carmel;
o NO ~S
3. MY QUALIFICATIONS:
b.
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 compietlon 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 -::ll'ldi'<<""""D.v,w.s CoI~r--~'<"~
'1)i\A(l,l)v--
I have attached a copy of my dipioma or certificate of graduation from an accredited school or
institution of massage J
D NO ~ YES ,-k [e.fff.. o'{ q?Ta.f,b~/o""" Csw-PS; 'i? ~s {Ae.r'.
a,
c.
I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate,
ilY'" YES
D
NO
4. MY EMPLOYMENT HIS
a, ~OOo ~ CYYl'ieJJ/
-year occupation
ORY FOR PAS! TH (3) YEARS. \VLJ"4"'f')'Sl...rrJ
. ~1r' ,~t 't<L'l)ven<><tio"ldC 5+~) 1&211
business name f1. city, state zip
(,,;?Ii)q7i'0b61
C;317)35)' '17't7
phone no.
b,
year occupation
business name
city I state zip
phone no.
c.
\1
. <\
year occupation
business name
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
o NO
'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.
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Signature bl-Applicant
Cc, \rO \. S- ~ 'K.'c- h h. 0. ."c.-r-
Subscribed and Sworn to before me this
Name printed
/ /-z:j;day of
, 20 Q..
My commission expires on h-b, 'Jj) ,20f2!l