HomeMy WebLinkAbout07040088 Application
.-~_~~ ,j>'i OF CA~e~
City of canneY
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
'NDlA1'I1'>
317571 2444 phone
3175712499 fax
www.carmel.it).gov
APPLICATION. MASSAGE THERAPIST PERMIT. $20.00
ct~RIGINAL PERMIT CJ RENEWAL [g ~ [g 0 ~ lir~,.:;;\-I
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1. APPLICANT INFORMATION 10
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a.
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last name
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first name
middle name
b.
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home address
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city
IN
state
4-b,}{J'l
zip code
c. On) 5% -)-'70,\,
nOme phone no.
('7Ii) ,"11 --q,-\?' '1
altemative phone no.
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email address
d. NooJ.,\lOIA.XL \)0'1 r~l\.
business name
tr\ . \' '~
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supervisor (if applicable)
(3n-)+Ob - 11,OU
business phone no.
e.
J-Il!:l. - A 60S t I\~t\. sf"
business address
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city
IN
state
Llli:131
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO cr 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.
r3NO 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 below.
/
ca NO 0 YES Date I Location I Reason
d. Attached is a copy of my Limited Criminal Hist6'ry'r~pori,.wiiich was provided to me by the Indiana
State Police no more than thirty (30) days prjor'tothe.dateon which I am submitting this application to
the City of Carmel; , -.
/ ' ~
o NO IZI YES
r::;
, ~ ,
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,
I:J NO i' YES Name of school I institutionl\l.(e;slo"J~ C/xlt$- INYf,1w1':
b, i have attached a copy of my diploma or certificate of graduation from an accredited schooi or
institution_of massage
." I:J ~~O li'L\,{ YES
c. I have attached proof of my professional liability insurance of not iess than $100,000 per occurrence imd
$250,000 annual aggregate.
I:J NO if YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a.l~'} ~~l \\.Q{y,p\f \No~\o\'\lt \),~ 1,k (1,,,,,,,\ ,~N Ll-lvD1J
year occup on T business name T- city, state zip
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phone no.
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1VU(i~\.;j ,IN ~J.dl\O (in l6'l\-Z~:;>'1)O
city, state zip phone no.
business name
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
I:J NO
ia'" YES
State of Indiana )
) SS:
County of Hamilton)
I attest that all of the above Information Is true and correct to the best of my knowledge and belief. I understaAd
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.
Dtiuv'wv flail ClAo{\)v\\" +-w,1\
Name printed
Subscribed and Sworn to before me this I D day of /If ,,'I
Signature of Applicant
,2007
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Name Printed
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My commission expires ond-- - (p - ( ) , 20