HomeMy WebLinkAbout07060058 Application
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~'l. OF CA.ltIt:
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City of Carmel
Department of Community SeNices 1 Civic Square, Carmel, Indiana 46032
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317 571 2444 phone
317571 2499 fax
wvvw.carmel.in.gov
1
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APPLICATION - MASSAGE THERAPIST PERMIT - $20.00 '
ORIGINAL PERMIT 0 RENEWAL 1- :/I:---() 7 () Ceoo 8
1. APPLICANT INFORMATION
a.
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last name '
b.
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home address city
hlllS:b Ca.-q S-13
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state zip code I
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email address
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c.
d. 1lo yYJ nn /J-h'c:VYla.'F(,(Q(_
busine;Jn'~" =- (} --;upervisor(ifapPlicable)
e. ~()~',re(cnJe
(~~ness address
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city
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business phone no.
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state
&f C0033
zip code
2. APPLICANT BACKGROUND INFORMATION
a. . I am eighteen years of age or older. 0 NO ~ES
b. Have you, within the past three (3) years been convicted, or plead Nolo Contendere for any crime of
unlawfui deviate conduct, deviate sexuai conduct or sexual conduct as defined in Title 35 of the '
Indiana Code. If yes, explain below.
~o 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.
~O 0 YES Date I Location I Reason
. ...... ~
d. Attached is a copy of my Limited Criminal History report, which was'provid~d 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 ''Ii.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 tsI YES Nameofschool/institutio~dA'uvt\R(ollo(Jo/-(;{~ll.lJ(/Lm
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b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o NO 'Ji- YES
c. i have attached proof of my professionai liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
. /
o NO '?- YES
'hts
Ct
4. MY EMPLOYMENT HI~~OR PAST THREE (3) YEA~~. . . .
aJJL:~] ~~Plf~~'businessname ' I . VJlI 'i ,s't!.etfO/ 3n~~~f5"S
brO.J..1Jd'i"?J(I.(I..l( 6. (ee.nb(l~h I r.
~ ~!Yy:~UwJtnv.r<J.f'8 f Ka-lla~JiM~h:,> m 3 1737;;;'- J;?CJ
-1:ear Q~upation Q~. :&~t1~;100!~ city,stat~ zi~ - I phone no.
c.rT)U05"~~ (In<f'P JOAr.V 317-'14Y063
year occupation business name 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 Hamiiton)
i attest that ali of the above information is true and correct to the best of my knowledge and belief. I understand
that any mater/aliy faise, misleading, or incomplete statement on this Application shali constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
efore me this
h () I dtl\^-O ""I
day of .ta-t.fIII-JL-
~~t!oElL r~~
11,1I\EU\-' ~. LUX
Name Printed
My commission expires on 4 I d 8 ,20 \ ~
,
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Na printe
if
,2007
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