HomeMy WebLinkAbout07040114 Application
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City of C"rmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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317 571 2444 phone
317 5712499 rax
www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
~ORIGINAL PERMIT
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1. APPLICANT INFORMATION I~ U'
APA 1 6 2007
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a. , I f.:::I
last name first naine I middle name
b. Sd91 C'-""'"y Cuu,.-f C(,...l'Fl1el /"", -)Ie, 0$5
home.address city state zip code
c. Y<I{,-;:'-{,{,o 7/&-- '717/- ",JI :r;,d;/CVJI" r ':/N:/~I . /'/~ ['--.
home phone no. alternative phone no. email address . ,
d. Go,d," o-r ;Je~~ -%..d '7/b - 'Ii IJ /
business name ".. supervisor (if applicable) business phone no.
e. ~-;?i?1s CQ""7- <2"'<-1"T- en. fins IlI //1-1 -/&053
busine address city state zip code
2. APPLICANT BACKGROUND INFORMATION
a_ I am eighteen years of age or older.
1:1 NO
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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.
D1Jo 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.
jjj( NO 0 YES
Date I 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 iiYYES
4/1'6ID7 ~ ~t~-ror Pl.\. ..,.0-
'f!-?;o/07 ~k\. ~d -+c (rno.-'.Q .I~
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.
D NO
ia" YES
Name of school I institution /ll,'dw"r /Jc"J,,,,,1' "f rI"c,;'';]) /!,..-b
b.
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
~YES
NO
D
c.
I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual ~~l9regate.
D NO ur YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a.dOtYp.~orl lIra;;,.';,....!"\':.. -Chcr'cJ"Jr c;5A/a<..:f Ant,')'! cJJO'J'1<:f~,..I~'f Cc,t"",J, /H $/bo53
year occupatiort-" business name city, state zip
;17- 93s-s-
phone no.
b.aooG 1110 H~ e fi."r'7Y":' f
year occup tion
G."I.>> of)!..."I,";:; -L.d (s.;t)
busmess name
CC\.Y'JktJ, fA! <;60";"3
city, state' zip
5"16 <5"(,(,0
phone no.
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year occupation
business name
city, state zip
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
D NO
~YES
State of Indiana )
) 55:
County of Hamilton)
I attest that all of the above information is true and correct to the best of my knowledge and belief. / understand
that any materially false, misleading, or incomplete statement on this Application shall constitute grounds for
denial o\:s application and/or revocation of my Massage Therapist Permit.
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Signature of Ap~' ant Name pnnted
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Subscrtb~r1)~r!iYi before me thiS ,..,('i day of "",d.....
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$ S- ..;;'~\SSJo,."..... 0 ~
itt>-C>O FEB. ~~~~ ~~__~~._--__
:. 16, ~j =- Signalure of No ~
- " 2012 I - ~
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-; 't -';:-:'t>" .,<fo"'" "'" $ ~" ~~'" ""'-' Q.:,'\.\..,
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'ft,~." My commission expires on {".:~\;,;. "-'
, 20..Q&
,2012-.,.