HomeMy WebLinkAbout07040073 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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3175712499 fax
www.carmcl.in.gov
317 571 2444 phone
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
~RIGINAL PERMIT
o RENEWAL
1. APPLICANT INFORMATION
a.
III N1 O~O~o'R- 'Q
~ firs name
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home address J city
2m!J:e~lD- 1743 ~~?atp.:h~R~ - Jtoq J
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middle name
b.
IN
state
----Y102~~
zip code
c.
m0n~:-n~f SY\V~ ~~(~l~~b,ernt\fSh
e. c2Dc') I 't':~ A~ l c\ r ro e \
business address \3>- if
317 - "Dl 4>-0 ",.(ro
business phone no.
:IN ~'fJ'V
state zip code
d.
city
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older.
D 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 / 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.
~ 0 YES
Date I Location / 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;
ONO ~
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 befor';) was awarded my diploma or certificate of graduation.
o NO IJI' YES Name of school! institution ~\O n l n l~ e.
b.
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of ma,.,ge
o NO f5I YES
c.
Ai'. attlc'lcd f0<,n~'Ce~~ l-
I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual ~regate.
o NO fit' YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a~~ -!l~~~Y115t(dto~usine~~~td ->\nts YflD-~~y~e SO(e5
'1 '%-577-77tf:
phone no.
b.
year occupation
business name
city, state zip
phone no.
year occupation
business name
city, state zip
phone no.
c.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
DYES
State of Indiana )
) 55:
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 apptication and/or revocation of my Massage Therapist Permit.
111t Cl Ct s. 14/ modo v Cl)(
Name printed
Subscribed and Sworn to before me this Sfh day of
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I
, 20Q2.
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My commission expires on
,20