HomeMy WebLinkAbout07050005 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
,_ _ ;;.'\.'l. OF CA.~.h
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3175712444phone
3175712499 fax
www.cannel.iJ).gov
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APPLICATION - MASSAGE THERAPIST PERMIT - $20.00 I
~ ORIGINAL PERMIT
o RENEWAL
1. APPLICANT INFORMATION
a.
'PI<. I GE 'f) 1-1 w I\J
last name t:t' name
0303 bUT/oAf LVOO/)7}z. ;Jr;6USI/I~
home address city
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middle name
b.
IN
state
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zip code
c.
30-7710- 3focfs-
home phone no.
317-5D'i - :').;200
alternative phone no.
d a wl1. mt1n-€ fj) inS 'jhiJ Db,
email address CMv
d.]}JWrJ t{fM.li- ~ Ci
business name
Ai /Il
supervisor (if applicable)
.'5/1-,'5D<t -,3~O
business phone no.
e. tf303 73 uni)/lI/;jlJD0'Dz-, rJ[)I!?UiSil'~
usiness address city
1M
state
16 Db;:).
zip cede
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO ~ YES
I
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 / 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.
~NO
DYES
Date I Location I Reason
----"'.
~;,-(" \'\' \
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d Att h d. . f L"t d'-;:; ..t?^ ~I~~t I 0.;;. rt~
. ac e Isa copy 0 my Hl)~ e ,L~f1Il}JJla -nlS ory ~e~~o ,
. State Police no more than tflirty (30)-?aYs prior\to'8l8ldat
the City of Carmel; , \\\J "'~ '
YES
was provided to me by the Indiana
ich I am submitting this application to
o NO
'f.Ct .~ pQ
5/1/01
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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.
I:J NO };(' YES NameOfsChOOl/institution13t}/;{INf)~~.YftODL '()fJ/45S;Jf,f-
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
I:J NO F( YES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
I:J NO ,( YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a.cOO'74-1vL-ISTIG-])fJWiclt;4R-/llFk-IU ;JOb...iSt/ILLIi /)ii4/tNa) !jbr-32Do
year /m~~n77t,(dsinessname city,state zip phone no.
b,::)<>{YQilct.A9iC7R..i'iC' :~,I.i tL(.'fJe./c,f, ;J()8t-fisvi{..,-~f;J 4b()("2- ~rf6- 3Z0U
year occupation business name city, state zip phone no.
c,:Jcei 4-bJ..-' '& T) e--trqt .'O/fJ..vAi J-1f!eiC.tS
year occupation business name
AiDBi-fi6Vi (..fj{ I/J '::!h{J62 6D 0'- 32tJu
city, state zip phone no,"
.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
I:J NO
~ YES
State of Indiana )
) SS:
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 i
denia f this application and/or revocation of my Massage Therapist Permit.
~
Subscribed and Swom to before me this
'])/iIJ}A.! /J.1/1;2IIi~c.i-
Name printed
S!-
f day of
.
, 2r:/J1:
Sl
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'flf
JVt?
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Signature otary
701'1 V rt. \I/t? 'fJj)1 f:7--tY7
Name Pri;)id \
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My commission expires on
, 20
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