HomeMy WebLinkAbout07040228 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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317571 2444 phone
317571 2499 fax
www.cannel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
d ORIGINAL PERMIT
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1. APPLICANT INFORMATION
a.
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last name
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first name
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middle name
b. ;UJ2:L eeOIl_Iyle/JooS C/avfdh..
home address'/ city /
IN
state
'It/IT
zip code
c. (3)7 J-,S37-<f,/9'!'-
home phone no.
[317) OcTI} - 77/9
alternative phone no.
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email address
d. )JtiQ55P?.Q tv/iJV i/,II",,?",/<. (,/'uP'lt" /ihu',h
business name / - supervisor (if applicable)
3I}, ,,'(?cO 600
business phone no.
e. 200 I G. 1::0-/5 r if g(YI
business address
CC/ v ,,, e/
city
J(V
state
L/(/ () 32
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 Titie 35 of the
Indiana Code. If yes, explain below.
Q1:io DYES
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 governmentai entity in the United States? if yes, explain below.
~o DYES
Date I Location I Reason
......-.--.--.......-
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d. Attached is a copy of my Limited Criminal History report, which was provid~d tome by th~"I~dianal
State Police no more than thirty (30) days prior to the date on which I am submitting this application to
the City of C,mel; .
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41.30/07 c.~'- ~ .A-ui..D.t' .fb r pv-...