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APPLICATION - MASSAGE THERAPIS~I~~
)tJ ORIGINAL PERMIT 0 RENEWAL iU ~
L
3 1 7 571 2444 phone
3175712499 fax
APR 2 3 2007
1. APPLICANT INFORMATION
a.
C reA', b
rYl .
middle name
S~Qr 01\
first name
b. LJ9SZ ~6k1lL eif. CarfYle-!
home address
c~tJth~~0- 9sYY
last name
city
:r II).
state
~&v3S
zip code
S c. r Gl:l:, (<V yczhoo.
email address
G 70 -3 /0 s:-ro
alternative phone no.
Co />"\
d. -;;; r- J< I e. <f As.:!.9 c; deo
business name supervisor (if applicable)
(.117) 'llf<g. ?rlol
business phone no.
:::CAJ . C{ f.v.D .1 d
. state zip code
e.
I {<f s:s: N. /fIUq,/;Ct-, CarYn~1
business address city
2.
APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. Q NO l:l('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.
.a( 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.
.la" 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 YES
If/?--5/07 ' c:cUl.~ft TO adV'i9 ~ J\L4 .pQ
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 success1ul completion of at least five hundred (500) hours of supervised
instruction before I was awarded my diploma or certificate of graduation.
o NO XYES Name of school! institution 1f1t;(lhdr:4 5,. h,., l 0 ~ .sc;.v,l-:fi "-
"1h4.r<>rL...I-; Cf - fTl4...,.,A/'I"--..:t=-tJ.
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o 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.
o NO ~ YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
ad. <90] /f706.,Q}f 7:.. ,,1<Je + As',? c Carr>1eJj f.-v' I.{ ~.~ 'iF!.!? 'J/ 0 /
year occupation {J business name city, state'zip phone no.
b<.?i'oo ~ /V19S6a~
year occupation
-r;,.rKh <I- A..5,S'oc.
business name
LQ~~;J,'Itx,.5;Z Sc;;?-S/OJ
city, 5ta e zip phone no.
o-:::X.005 ~4 f(F
year occupation
Sj~ eh>~"'r.Rd
business name
~.LI .::;::.,...u, 91,.053
city, state zip
~ Ck,- 5's9'I
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
KYES
State of Indiana }
} 55:
County of Hamilton}
I attest that all of Ihe 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 andlor revocation of my Massage Therapist Permit.
~WVf(1 711. C.cV.L., Sharo/) ;fl, C rq:/n
Signature of Applicant Name printed
Subscribed and Sworn to before me this
day of
.20~
Signature of Notary
Name Printed
My commission expires on
,20