HomeMy WebLinkAbout07050124 Application
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~i. OF Cr\l?<lt
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
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3175712444 phone
3175712499 fax
www.carmel-in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
)I{ ORIGINAL PERMIT o RENEWAL :to7cf:tJ/f1J. ./
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1. APPLICANT INFORMATION ,
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a. -;?ip~ , -";;;;;;rh/~/e{frs/2) \\nl MAY r 5 2007 I
lastnam first nam TDm~dle name ~
b, 1'101 <~h(,/I'"'f' Or: Cume/ ~ f~Q1'Ce~
home address city ZIp co e
317- g4,-/-I" tiC} 7 -' dlii~/)t.( I!hrrt/J'la;/ 'to>>}
c.
home phone no. alternative phone no.
em 11 address
d. J:s'~ - .3/1- 'i{'J<1-5X/?
~j) Ie, Ii '{-OK
business name supervisor (if applicable) business phone no.
e. /1R'D E. //t, 1$'5.,). S7e.o?'/O C~e fJ1 E l- JAJ L/?03~
business address city state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years ot age or older. 0 NO fi 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,
fNO 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.
7< NO 0 YES
Date / Location J 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 "#' 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
~ YES
Name of school! institution ffEIIL1!1 tfA/te/CHJYI EAli
b, I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
I
o NO 91' YES
c, I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate,
o NO
'1 YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a, J9.!l!1 (f/115<;1f6-~---;t(',1 ,y;,r f -:;;;i6tijbl(
year occupation bu~iness name
C#rrlG l.- J(J 'I~3ci'-
city, state zip I
gjf7-
521'/ g'
phone no.
b,
year occupation
business name
city, state zip
phone no.
c,
year occupation
business name
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 ;S- YES
State of Indiana ) , ,r-O
) 55: 051- 50- 71:2 i
Counly of HamitJon)
I a/test that aft of the above information is true and correct to the best of my knowledge and beliet. I understand
that any materiafty false, misleading, or incomplete statement on this Application shaft constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
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Name printed L
u S~d Sworn to before me this 4day of ~"
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My commission expires on Z , 2012!/
,20127