HomeMy WebLinkAbout07040175 Application
,4}.. 0 '7(;40175'
City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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317 571 2444 phone
317 571 2499 fax
www.carmcl.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
.~ ORIGINAL PERMIT D RENEWAL
1. APPLICANT INFORMATION
a. ~Y1r Ard(fO. L
last name first name middle name
b. \ mlLlYY\pO\"I.\ IN 4tP21R
city state zip code
c. 3D. Q2..D. O<i{\ lP XI. 5\~ 12Y\- ~UllV\
home phone no. alternative phone no.
d. !!Jn~~~fJ ~ ~ ~ <?11p DlPCD
supervisor (if applicable) business phone no.
e. 200J E .\51~S~ 't>~ Ur~\ -IN 4-to D~2
business address ) city slate zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO 'I:f.- 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 beiow.
~NO DYES
Date / 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.
)l. NO DYES
Date / 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;
D NO \J{ YES
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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 ot a state other than
Indiana that required my successful completion ot at least five hundred (500) hours ot supervised
instruction betore I was awarded my diploma or certiticate of graduation.
o NO ~ YES NameOfsChOOl/institution~\(\Y'\ t()\Vc9-t
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o NO tI YES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
o NO
~ YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a~ ~~\)~uSin~~~ t~ el!i~L Iz~ 4{qD32
<ll{P'Dlof)()
phone no.
btxO~~7 ~ A
business name
~
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phone no.
c~ -,!1;~ir~n(W\ \ ~i~~~a~\'lct( ~Vl\ llOY\ \~ft~~~ ~%1.02-
2'1<6- ~~m
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
)I YES
State of Indiana
ubscribed and Sworn to before me this
Namefrn0rffA l. Wrljh~
'7 daYOf~'20DJ
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Name Printed
- 20J!j
My commission expires on