HomeMy WebLinkAbout07040057 Application
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. -*07Ci-foo57
City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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317 571 2444 phone
317571 2499 fax
www.carmel.it;l.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00 ,
]if ORiGINAL PERMIT 'fl,ol ~(L N;c.<TLile- I ,L
D RENEWAL 'l.:'f~ 67 <y.(Y)) +0 ad"j~
p.~ f)Dri,L1 I
1. APPLICANT INFORMATION
a. Zoll;",5e'f -\.AV\eV\c~ , Ni CO Ie.. ~o..V-;~
last name first name middle name
b. 5<6;)5 A~\e~ydE'.G, LtH"^-d I~ 4\.eD33
home address city slats zip code
c. Q IlJ5<OCj -0<:" 30 <31 i) "'\ \..t\ -'b'(c(oO~;l\) i\'j\I\7_r{\I1f'v'ci,@hutilltt~ I.
orne phone no. . alternative phone no. amall address
d. 1>YOf'eSS\ C'VItI. \ t=",''''ess 5,r:,~et..A5 II \ 0. (3\ll "\\"\ -&<0(00
business name supervisor (if applicable) business phone no.
e. .'J'bd5 A-iF\eg:&~f' O. C C\. rMe\ l~ 4\oDS3
business addrs If city state zip code
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2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO 'ji?'YES
b. Have you, within the past three (3) years been convicted, or plead Noio Contendere for any crime of
unlawfui deviate conduct, deviate sexuai conduct or sexual conduct as defined in Titie 35 of the
Indiana Code. If yes, explain below.
)(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 revoked for cause by any governmental entity in the United States? If yes, explain below.
~ NO 0 YES
Date I Location I Reason
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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.
o NO X YES NameOfSChOOI/institutionj\~UOiVlI;Lv\ 14'3G 5dANI) I
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o NO
~ YES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
o NO ~ YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS. ::r: ~~K ~~<'J:r .jo "5evfP<N"t.
a.(jOO(P Mac.~ll\(ift{J.is+ "ell (f;Vr'MJ.~~.) Gv~), 1..&l..~j(ro3-s ~ /4-])(0(00
year occupatio business name city, state zIp phone no.
b.~ 1-11 ".,-{'let"" (pr::-S) CV.L-U11/A/4uoS3 4/4" llJu..o
year occupation business name city I state zip phone no. ,
c.2QQl HI (('\ ( (f~~ (' C(.....rj.A~) I I A / <i WifS3 414.. '/Gum
year occupation business name city, state zlp phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
}i 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 knowiedge and belief. I understand
that any materially false, misleading, or incomplete statement on this Application shall constitute grouilds for
denial of this application and/or revocation of my Massage Therapist Permit.
/Y\ VV\LbA/I 0 I A J ^---' 1\.\ uh ~. ZJ1 U&lc.0-.
~lgJatJre ~t Vv''-'-NV'"'V Name prtnted
Subscribed and Sworn to before me this C;M day of A-prll ,20l22
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My commission expires on
,20