HomeMy WebLinkAbout07060034 Application
~'{ OF CA.l?~
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
ENDlArll'--
317 571 2444 phone
3]757] 2499 fax
www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00 I
XORIGINALPERMIT 0 RENEWAL ,JI;() '[) 0037'!
1. APPLICANT INFORMATION
a. la)~['JC::I). n firs~~
b. \.;)\a\ 'Iz N.lI\;c.hi~()"() 2d. Z;onSo; \ l~
home address city
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) ~ LilI;077
stale zip code
c.
3n- &'fo,-3~4Lj
home phone no.
~-53;2-IOllS5
alternative phone no.
t..)d\dc.; 2#~hx>.c.of>1
email address
d. ~~~~~~~;\ap~~;\ih
2) 7- 7CiD- \ -:v:JO
business phone no.
e. 8 \<6d- ~ ~s-Hl1aib CrM-r0+QiL
business address S. t city
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state
~U03d
zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. D NO )(Y'ES
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.
f;il:fio 0 YES
Date / 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 / Location / 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 J(" YES
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3. MY QUALIFICATIONS:
a.
I am a graduate of a school or institution ot 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 "I..UPO -=r.. \h e mpeU+-; c.
fi\o.sS"4f:- \' rt>~ ('(:L.{"V"'
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
o NO )l( YES
b.
c.
I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate O\,;)l\e\ O~ ~ ~ bcu se St>o..
J( NO 0 YES Y\o...S ~(.)~ Cc0eQ)..~.
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. leo' M\T) iCl ~ ES2.0 (-"nw<",",llfunL..JNi~I"']:'t--:l 1.( (pUo8 317-298- J."I75
year occupation business name city, sta zip phone no. 1
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b. ZC;:} oc~~S \~~am~;fH~chd 1y~lz~~{o2(Og- cl7;t?n?0?l
c JJJt occupfL II
busine:! L1e
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city, state zip
'itto
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21
o NO
.,r YES
State of Indiana )
) 55.'
County of Hamilfon)
I attest thaf aff of the above information is true and correct to the best of my knowledge and belief I understand
that any materiaffy false, misleading, or incomplete statement on this Application shaff constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
Signa~f~atLO~ Nam6;.~ \Ao<oOfJ
Subscribed and Sworn to before me this ,;i!J7{tdayof 71uGrr-
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Name Printed
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My commission expires on /1111<-/ :2 ,20J'j.
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