HomeMy WebLinkAbout07040052 Application
~'i OF CA~
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T it070'iOOS~
City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
lNDlA~~
317 57) 2444 phone
317 571 2499 fax
www.cannel.in.gov
APPLICATION - ~~~S~tiE~Tt/leR~p.I'II~~ PERMIT - $20.00
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ia ORIGINAL PERMIT n' 0 RENEiMA~ <J.v, u- ~ N<1f.cc r-
II ill APR 30 2007 III I ~(lYt.I.DD~ cpe .'
~ I ! I I
1. APPLICANT INFORMATION l
a. J~ , j"tI-I.jqt;'""L- Tl'11M~
last name first name middle name
b. rJ.4RZ. SJLVElZ.. I)ffk, Dki::
home address city
Lj '1 /-I q /.pL/
home phone no.
((~jW~
rAt L//df)37_
state zip code
c.
{ r/? 7 -:Ptl/ '7
alternative phone no.
JI;/ Ie Jt/4I3L1-Imfc, (/J/.17V Dy,
email address
.(orvl
d.
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business name
--
supervisor (if applicable)
1(i1/-cll7
business phone no.
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state
J/lo077
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 1:1 NO a"'VES
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
Ind,!ana Code. If yes, explain below.
Jil'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.
if NO 0 YES
Date J 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 ~YES
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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 at supervised
instruction before I was awarded my diploma or certificate at graduation.
D NO lOt YES Name of school! institution Pg~ 11:i.h<d.M a~{ Jiltl M >/rbio
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
D 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.
D NO ~YES
4. MY EMPLOYMENT HISTORY FOR PAST THR E (3) YEARS.
a.~ 1:f!uf.f:f191 bU!i~essname ~~!ijpJy\
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cZQf;tj ;1JLU1IA4K? -JJIf/J thllU/;rJfO{jr {'(U~)~
year 668upatl~ f;mess name ~ CIty, state Zip
ItH7-710
phone no.
!.rf.?1-Z,7J7
phone no.
!m-Z7/7
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
D NO
~YES
State of fndiana )
) 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 aterially false, misleading, or incomplete statement on this Application shall constitute grounds for
denialllf is application a~,!or r vocation ot my Massage Therapist Permit.
1//.. ~ / lu/I-.? JdlLAAE-L -}'-+\-r1T'l~
Sign'f'{.' 0 Ap ieant ~Na";t printed
ubscribed and Sworn to before me this JJI day of ~;,j , 2007
Signa:~I., mf'~
- /( e III /( 1'l!ov'~~ LVi
My commission expires on 06 /1 :?
Name Printed
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