HomeMy WebLinkAbout07040058 Application
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City of Carmel
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~'i OF CA.l4t
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Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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317 571 2444 phone
3175712499 fax
www.carmel.in.gov
))'dAPPLlCATION' ~.,~MASSA~E THERAPIST PERMIT - $20.00
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)1t ORIGINALPERMrr-'" " ,
D RENEWAL
1. APPLICANT INFORMATION
a. '00.. t \ 11 n\
last name
:s he r 't-l (5 he-r't)
first name
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middle name
b. "Bn'1 IAla.de.. ttilt Lt:. JJ\.dil1,V\o..",,,ljs ~ 1...f~;ZS'
home address city I state zip code
! . c. " {~:\ti'?ne~. ~~ ;%7 Q. ~.. (~t~1}~~92p:G(.:t.~. '"''oil ~~~I~~~IA~~(j ~CQ! ao I co IYt
d. ~\\.o..r('.\ '1h.u,-pe.vik ('3lL) '-l 5 n - 0.;( \ ;;(
business name l business phone no.
e. \\~O ~t.d.l~a.\ ~-+.
business address
c.o..r Md
city
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state
c..{ltzO"3;2
zip code
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. /iNO DYES
Date I Location! 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 DYES
" ,
Date J Location J 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;
D NO \&1 YES
'11'3/07 c~<,\ t'.~~ r-
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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.
0 NO .)it YES name of school I institution tl1e)(a.i\J..t'"~ll 'Sc..\oo\ o\. :Sc..ie(\.{,'~i
\\-.~r-Il.ee.v~c..s .
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
0 NO }'t YES
c. I have attached prpof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 a~n,~al !,ggregate. . . , ,. , ,
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0 NO YES
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4. MY EMPLO:~ENTHIST~RYFORPAST T~E (3) YE~~S. . <2(1)
, .- ,J200rJr . .. 'M ":r." " "'Bo.;~~r:~ ~r;~~v , . c.a. ., .t" 'IN' .H'SO"O ~ l:t
~"t" .s:.......' "S';."'Q'':' '.~L'" l"M.e.'. "
year occupation business name CJ city, state phone no.
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b. .. . ;.. . :.:j. .' ,- . , .'
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year occupation busineSs 'name city, state .. , . phon~ no.
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c. .. '". . . ,'.; :.-', . ~ .'. . ..; " . ',,"j "."i'
-
year occupation business name city, state phorie no.
.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
Xi YES
State of Indiana )
) S8:
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 of Ap
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t {9jub~~asrvo
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to before me thIs -/--day of
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My commission expires dn PrLb. ~O , 20j}J
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