HomeMy WebLinkAbout07050105 Application
APR-09-2007 MON 01:01 PM
FAX NO,
p, 01
.' . (;-0-'" of CA~<t
lNDlA't'i~
City of Carmel
Department af Community Services 1 Civic Square, Carmel, Indiana 46032
317 571 2444 phone 317 571 2499 fax WWIV.canne!.u,.gov
APPLICATION. MASSAGE THERAPIST PERMIT. $20.00
'A ORIGINAL PERMIT
CJ RENEWAL
1. APPLICANT INFORMATION
a. V(')IAJm"n
lastliame
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f1rEitname --
hll'\e.
middle name
b. 90 w. eO Inl ,~.
home address
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city
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state
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zip code
c.
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home phone no.
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altematlve phone no.
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emall address VC",-'rf\:J:),. C.:;:y.r.
d.. tJIo\,~()Cjf'. f '(\'>1'1
business nama
~(yii'? \'-'\O'~h
supervisor (If applicable)
(~\ ') 'Z\ 110- ()lCC'S::)
business phone no.
e. '2c:\\\ F. \')\~ ::'ITrH\-1I: ~()Y(Y\P\
business adOress 6'0tf
2.
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APPLICANT BACKGROUND INFORMATION ~ J \
. 1\ MAY 1 5 2007 1'1
a. I am eighteen years of age or older. a NO ~ YES U __ . . ..l::~, I
b. Have you, within the past three (3) years been convicted, or Plea~ Nolo Contendere for any crime of
unlawful deviate conduct, deviate sexual conduct or sexual cond&gJas_deflnedjn_Title,35,ofJhe,~J
Indiana Code. If yes, explain below.
~ NO Cl YES
Date I LocatIon { Offense
c, Have you, within the past three (3) years, had your massage therapist's license or permit denied I
or revoked for cause by any governmental entity in the United States? If yes, explain below,
/A NO Cl YES
Oat. !location ! Reeson
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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A~R-Og-2007 MON 01:05 PM
FAX NO,
p, 02
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3, MY QUALIFICATIONS:
a. I am a graduate of a school or Institution of massage therapy which 15 accredited by the Indiana
Commission of Proprietary Education or similar stete 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.
(J NO Fl YES Name O!schoolllnStltution_"'nY'\ (1('\ ( CJ\\ l2>0f
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
.\il NO illi YES \',Q."<::.",,,.. 'c. <.lc.\J~J "'I 'I ~\ '.
c. I have attached proof of my professionalliabJlity Insurance of notles. than $100,000 per occurrence and
$250,000 annual aggregate.
. NO
& YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS,
a..ru..... C\())\j\<?\'lr\\':iI\\..c:., ~ \lID'))I.rss.(jJI':..
year occupation business name city, state :t.lp . phona no,
b.~ :J::1yitT'1Y1i ~O::("J'"\/""'''''''~vY\i(fi\''V ItYI'nnc;!p7fif,'" JU
year occupation ; busIness nsme clty, state
phona no.
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year occupation
~ur~{t\\"~
usln name
i Q)Xlf)(\Y'\ )1\11.)( 0\)S'2
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 (J NO \Zi YES
State of IndIana )
) SS:
County of Hamilton)
I attest that all of the above InformatIon Is true and oorrect to the best of my knowledge and belief. I understand
that any matarlally falsG, mlslaading, or Inoomplete statement on this Application shall constitute grounds for
denial of thIs application andlor revocation of my Massage Therapist Permit.
'A\\"'\\01\.'~ l nl)n " ArC\ve.(', :N."i d'(Y'\(l V\
Signature 01 Applicant Name prtnted
Subsorlbed and Sworn to befo", ma thIs i'D daYOf^p,,;\ ,2010
Signature of Notary
Name Prtnted
My commIssion expires on ,20