HomeMy WebLinkAbout07040202 Application
:!t B7C1-f 02-02-
City of Carmel
~'{ OF CAlttt:
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Department of Community Services 1 Civic Square, Carmel, Indiana 46032
INDlA~'"
317 571 2444 phone
3175712499 fax
www.carmel.in.gov
APPLICATION '. MASSAGE THERAPIST PERMIT - $20.00
'ORIGINAL PERMIT
o RENEWAL
1, APPLICANT INFORMATION
first name
Eli~
middle name
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a, r~S:te;; n I<el 0-
b, J2Sf'fS W/(\&..50rD~ CarrNl
home address city state zip code
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home phone no.' alternative phone no. am ail address
San dra...
;5ard~ t . SJe1 nk.&vJ r.J A-
business name CJtN p fVI$I\J j ~ supervisor (if applicable)
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e. J2b/'6 WilLd.sorJr ~
business address city
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business phone no.
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state
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I,am eighteen years of age or older. 0 NO ~ES
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.
~ 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.
"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;
o NO E0ES
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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 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 name of school I institution A! e K. ttnd t( tf S~
<.5e.1~ G 1 CS'
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of ma~e
o NO c! YES
c. I have attached proof of my professional liability insurance of not less than $100.000 per occurrence and
$250,000,annual ~egate.
o NO cs( YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEAR ~/ 7-8'1fW <1'11 G
a. 2ti:4 ~~~ t s Ca. r.rr-01 I IJJ 3/.':f-l.f(oO-02J q(i)
business name city t state . phone no.
year
b.za6 " '1 --I, "
year occupation business name city, state phone no.
II ,.
c. '2lclP I. II
year occupation business name city I state phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE ConI + ~::r:r,WN.:f)
I have received a complete copy of Carmel City Code Section 4-21 U NO 0 YES PI e4S!-
CO
State of Indiana )
)
County of Hamilton)
SS:
(1.~1)
DOROTHY J. THORNTON
MARION COUNTY
My Commission Expires
Fob",. 12,2009
I attest that all of the above informa Ion IS est 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.
~a~'/~ ,
Subscribed and Sworn to before me this ~day of ,2rf41
I
My commission expires on ,i h /t
, 20.21