HomeMy WebLinkAbout07060085 Application
APPLICATION - MASSAGE THERAPIST PER.
010fpOOES
City of Carmel
""_'m", ",,"m""'" "'m~ , 0"" "'""" """"', '" ~ ~ 0 VI ~ ~
317 571 2499 fax
www.carmel.
_ i~o~ao2007
r ~ 'i OF CAl?<It
v' i ~<
11\TDlA~l'>
3 17 571 2444 phone
r:p.. ORIGINAL PERMIT
o RENEWAL
1. APPLICANT INFORMATION
a.
J.:nill.er
last name
\ACt01e;n ~
first nS"me
~(in'l
middle name
b. 6 '5 S. [loth JI-.
home address
~~.
t'--.\o tJeJS\J III L
city
:krJ
state
;.f leD lJ7 {)
zip code
c.
3i1- t..jO':)-Ct635
home phone no.
alternative phone no.
~il\Uolsi-iIr.5e.~.
email address
d.
Qo rol'l Y\."5lj'~hl JiS
supelVisor (if applicable)
oL.j~ - Z:?!:r
business phone no.
e. ~~:.-L3e~eI;11P Ad,
-fl1rwvl
city
':1N
state
J../. loolP (I
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. D NO ~ 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
DYES
Date I 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? If yes, explain below.
~ NO 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 of Carmel;
o NO
}ill YES
(
~~
tplo/67
~
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 rti- YES Name at school I institution ~1ec Y\ CoII~
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o NO " 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
,. YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a.J.ock; ~O f'\j)V DuVe~~im VnUBULVJ C-orrneJ:tN
year occupation business name CIty, state Zip
''In-l)lij-Q,Z3
phone no.
b.~ ~ d'-R~i<<~
year occupation business name
1Y1rJiCll1cimJ6TN
city, state zip
3n-'5,r-Ylbl
phone no.
c.~jlJrmn~
year occupatio
Ne,ih'\\\MM ~ley
business name
fr:H.~ ,lie, r:J\j Llloo'io
city, state zip
'517'~' ""&110
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
DYES
State of Indiana )
) SSe
County of Hamifton)
I attest that all of the above information is true and correct to the best of my knowledge and belief. I understand
thai any malerially false, misleading, or incomplete statement on this Application shall constitute grounds for
den I of this application and/or revocation of my Massage Therapist Permit.
a ~rl'~ [LHI/eL,
Name printed
Subscribed and Sworn to before me this'1.J-h day of ,-l.U'/Yl.R- ,20D7
~f>'~
Si nature of Notary
Y A-.!Y\ e. L-It-_h, ~
Name Printea
My commission expires onilf1UD s;).-5, 20~