HomeMy WebLinkAbout07040149 Application
."
City of Ca;mel
Department of Community Services 1 Civic Square. Carmei. Indiana 46032
~'i OF C.4ltlt:
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l:NDlA~t'-
317571 2444 phone
317571 2499 fax
www.cannel.in.gov
APPLlCA liON. - MASSAGE lHERAPI1~~U V:$"!~,~~
IilI ORIGINAL PERMIT 0 RENEWMI~\ I I
I APR192007,i
I " I I
[ WI
1. APPLICANT INFORMATION I
a. Soude.t JE'I-'\Y\;re..r t-\U(;e.
last name first name middle name I
b. ?,~O N. Rde'j AVe. :rnd;C\....apcliS LlJ 4102.01
home address city state zip code
c. (31,)35.2-15",(, (31,) 502.- 'TW.. ::rBlac.1< 330@Qol.c.o""
home phone no. alternative phone no. email address
d. Mo.S5o.~e. !:::nv,/, c..""o(\il' 1"\0 ("Sh 0'1) crl /,,-0 1000
business name supervisor (if applicable) business phone no.
e. IQSOc,.e'{ \.-.owd PQSS Ca(Me.1 :r~ L\lu031-
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 Title 35 of the
Indiana Code. If yes, explain below.
~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.
ll!l NO 0 YES
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;
o NO ~ YES
iJ/~/61 ~ !'w.c~ Por <pu.
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 ~ YES Nameofschoollinstitution ::r:nd;ana BL/Siness r('}lle.~e.
b. I have attached,acopy of my diploma or certificate of graduation from an accredited schooi or
,.. " .... "'I""J.
institUtion of massage ::Cho.ve. o.o\.to.c.\.,e.d Q, le-tle.r -WO"" :J;:BC.. ::c. ~; I}
~ NO 0 YES ~ev.ct Q, C.of'i of cfl1' lo"",Q W hoc \'\ :]:. fec.el ve.
.+ ;" +,,,,e, W\o.,1
,
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
I
$250,000 annual aggregate.
o NO
~YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. p~1~~ ~~u;.~11"elI"'U b;';~:<;;a~:eSCh6oL ::~~tt~~;,;:tJ 4(..201
1)00- .,
b. ~l":; ~.\-IC....."l
year 0 pation
I
3Sb - 1 23/
phone no. I
w~l-ma.(+
business name
~Jb ~2p~0:~!f~
ql~I~.
c. -1L.L.U ttl:lCI.EY
year occupation
\I t'YlC 1'1
business name
~V\tynl~i 5~-r"1 YillQ 35~:On~/!tJ J-
Cl~ e Zl
.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
ifJ YES
State of Indiana )
) 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 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.
~~~~_ CM.
~ture of Appli nf
~
hn;-f-e.;- M
Name printed
,2re2
Subscribed and Sworn to before me this It day of ~ .
>>dV 02/f~
Signature of Notary
YfJ/rU({ {/ 1/JJ.irA.-
Name Printed ')
My commission expires o/t~
, 200e;