HomeMy WebLinkAbout07040152 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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3175712444 phone
3175712499 fax
www.cannel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
~ ORIGINAL PERMIT
D RENEWAL
1. APPLICANT INFORMATION
a. Kr i lYItY1d j ij1nlf~ ~(l
last name first name middle name
b. ~ ~t7"I~( 'K\d~ e :PI lr1dt'4IIt'fo/t'S IN 4102/0D
home address city state zip code
c. ~17-4ID-wz.O 311 - '360 - O?f51o J<ritn{ ra.l3D@~w. Ci:wl
home phone no. alternative phone no. smail address
d. ~;es~~Uje T~ 317-4/0-202.0
supervisor (if applicable) business phone no.
e. ~~a~~( t?t~ PI ( nd i~a.po it '5 I ~J 4V2bo
city state zip code
2. APPLICANT BACKGROUND INFORMATION
I am eighteen years of age or older. 0 NO ~ YES
Have you, within the past three (3) years been convicted, or plead Nolo Contendere for any crime of I
unlawful deviate conduct, deviate sexual conduct or sexual conduct as defined in Title 35 of the I
Indiana Code. If yes, explain beiow. .
a.
b.
liNO DYES
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
DYES
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;
D NO Ii 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 ri YES name of school I institution VftJ1 Co 1/e1e oF ~e 1herUf~
b.
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o NO rd YES
I have attached proof of my professional liability insurance of not less than $100,000 per occurrence an1d
$250,000 annual aggregate.
J YES
o
NO
e.
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a.~j~~~~ 1htl1P'~usin~~~:' ErrlfOjed J l1~t~:~:tlis, I ~
b v~l;;t - /.A1R<tD9 lfx1Po,sr
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10105 -
cp~~t, =;rt ~!~ n~!,~t
317-4/0-2020
phone no.
1nd::~rl/s.l~
Jnq~~:!FII~, IN
~7-l?fHs>-:JtZ7
b~m~~
phone no.
3!i-7flq-&COI
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
" 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 knowledge and belief. I understand
that any materially false, misleading, or incomplete statement on this Application shall constitute grounds for
~al of thi apPIi1ition r:1or re1)ation of my Massage Therapist Permit.
~ ,1\ n9<-~ (f\/);fv A ,Ki;/l"\m<\
Si9[J re of p 'liean!
Subscribed and Sworn to before me this :{O'I/I day of {}f))~t
Signature of tary A j . / dd'
JrtL y 71', fIV~ f
My commistion expires on
,2r41
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