HomeMy WebLinkAbout07040148 Application
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City of Carmel
Department 01 Community Services 1 Civic Square. Carmel. Indiana 46032
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317 57l 2444 phone
3175712499 fax
www.carmel.in.gov
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APPLICATION - MASSAGE THERAPIST ~~rWTg~~,O~9~ 'n,!
~ ORIGINAL PERMIT 0 RENEWAL II~~I I
I i I APR 1 9 ?nm
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1. APPLICANT INFORMATION
a. O\)...)-CL-'i\ S . Pn,C\ ()/\ t:\ VQQr\
last name first na~~ middle name
b. '-\. 'CJ N . CC'\ \<\cx.rd A \Jt :L~t+; \ IV L/ 0'.;:W I
home address city state zip code
3\'1, \/',\ \.\. Z:;(C III ~~e. \A. 0 v",\t.h <; @ I
c. c.... f\',-O"\ \ . C 0 (V\
home phone no. alternative phone no. email aljdress
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d. (1.'\ (xc, '::0.. C, "-- f:,\ \.j q ~\\(),( \\ e ('j\O ,C,h 3\i-'6llr-Dlq()[) I
business name \ supefVisor (if applicable) business phone no.
Iq~ 6relfhou."d{XlS:) rCi'IIM\ -:5:0 Lj In ('yO?, =< ,
e.
business address city state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO ~ YES
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 Tille 35 of the
Indiana Code. If yes, explain below.
riNO 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? tf yes, explain below.
fiNO 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 l( YES
'-+/8.010-7 -;P.QJ\tmiJ: \\QClcl~ ufpI p-tA.
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.
Name of school/institution .::I.f'\~ 'I r A "n K \.A <:., \ !\ (J C, C;
Co\ {Ie:.}.. - '0\{lO '< cec\ CQr;\p'-'- S
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
D
NO
~ YES
b.
D NO
'fA 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 THREE (3) YEARS.
a ~ ~~s,~~:; \- ~~\\u. ('\c\.. -\-u (Q\ Q :S1)\A.\-\WI){~ 3. to
year occupation business name city, state zip I l\ CD d-J"l
''Sil.l'l \ .9lnlo 0
phone no.
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b.~ ~. r 'ie, \-
year occupation
r'f\ClS~~ <c:.n'JU
business name I.. \
00-'.(1'1\<0.\ "3.r-) q 1,,0'51. 3(1.'t'i1^.Q(OOO
city, state Izip phone no.
c~ ?fo'~e\-CCQ(r.I'M\o( ~\;;{~r> A'sscC
year occu tion business name
"'::S"rx\.[) \S\ ':3l\J L((o').~,/ "'317.;2<),./;3"3'1
city, state z p phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4.21
D NO
Il2S-. YES
State of Indiana )
) SSe
County of Hamilton)
I attest that all 01 the above inlormation 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 revocaiion of my Massage Therapist Permit.
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A. '(\Cj Q lPl- "7, () LA.! e h <;:
Name printed ~
Subscribed and Sworn to before me this If? ,day of tJ!-p,,-<t--Y
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Signature of Notary IJ
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Name Printed
My commission expires o;;;l:c'-4"O 6,20 d.F
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