HomeMy WebLinkAbout07050048 Application
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01 05 C0f 1
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.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
CitbRIGINAL PERMIT
o RENEWAL
1. APPLICANT INFORMATION
a.
tJ r7l f'fJ i
last name
Ih~sa
first name
J
middle name
b. .L/~6d akflCtl/OI /aJ7e- Ii1a!tMMolt.i
home address city
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state
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zip code
c.
(3d 5L%}-3;5o
home phone no.
(317) P5'O-903fo
alternative phone no.
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email address v
d.
(!J~~~e. 1I/](/(/
thtrlte. /Y)f,(rSh
supervisor (if applicable)
(317) P/(,,--oc,tJ{)
business phone no.
e. A,IJI)/ E 1S7S1'.s.,-"'-QC/f
business address
{!tifme/
city
TN'
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zip code
state
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO iiY'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 01 the
Indiana Code. If yes, explain below.
ill1V'o 0 YES
Dale J Location / 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? II yes, expiain below.
~o 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 01 Carmel;
o NO ~ES
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 ff 6ff_s:s/ oNd (Ju:aY5. 1/ls-hlufe.-
b.
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
~ES
o
NO
c.
I have attached proof of my professional liability insurance of not less than $100.000 per occurrence and
$250,000 annual aggregate.
~S
o
NO
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
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a.d-.DDf" /J111<;9Jt 7/xrt'f'JSr ;,J.bJ Ar:-AiJtk. T/V!JP(5,IAl
year occupa 'on business name city, state zip
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phone no.
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b~ /J1AY;;a1C //V"I";V- a'lf!'// U:/JTlr
year occupation business ame
F/slY'/I: ,:VU
city, state zip
5<f::;-Qtj'/O
phone no.
c~f1J/f FT .:5-H/d//lf
year occupation
1'nAssIONilI (b~
business name-2'/2}; .
I/IJd'{S I TN
city, state zip
d.'13-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
[ji/YES
State of Indiana )
) 55:
County of Hamilton)
I attest that all of the above information Is true and correct fo the best of my knowledge and belief. I understand
that pnyTll,3teflally false, misleadmg, or Incomplete statement on thiS Application shall constitute grounds for
~110f this applica~ion andlor revocation of my Massage Therapist Permit
UOlA'o/)(ltl(-<:~~~ ' vJ/lJ1SSa J.6n:Wi!J:
SignalUre of APPhcan~ .-J'... ) Name pnnted
Subscribed and Sworn to before me this -+--day of
,20JjJ
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Name Printe
My commission expires on