HomeMy WebLinkAbout07050158 Application
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
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317571 2444 phone
3175712499 fax
www.carmel.in.go
D ORIGINAL PERMIT
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last name
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first name
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1. APPLICANT INFORMATION
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city
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home address
state
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zip code
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home phone no.
alternative phone no.
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business name
supervisor (if applicable)
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business phone no.
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business address
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city
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state
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. 0 NO r:t 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 below.
'r:::j.NO 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 governmental entity in the United States? If yes, expiain below.
~ ~ NO D 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 of Carmel;
D NO \( 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 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 )l( YES NameofschOOllinstjtutjon-1lJeXandr~ s.J,oof ".,+ 5c;ef)fJ:c:.
1h.er:tfecJhcs
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
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c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate. I'
o NO If YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
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year occupation business name city, state zip
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year occupation bUSiness name
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year occupation' business name fj-I'
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phone no.
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city, state zip
phone no.
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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
o NO /{YES
State of Indiana )
) SSe
County of Hamilton)
I attest that all of the above information is true and correct to the best of my knowledge and beiief. / understand
th any mat riaHy ~ /se, misleading, or incomplete statement on this Appiication shall constitute grounds for
d n I of this appiic lion and/or revocation of my Massage Therapist Permit.
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Name printed
Subscribed and Sworn to before me this ~day of
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Signature of Notary
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Name Printed
My commission expires onllpli.QJ 6 , 20 is''