HomeMy WebLinkAbout07070172 Application
City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
I~
INDIA"t'<~
317 571 2444 phone
317571 2499 fax
www.cannel.in.gov
APPLICATION - MASSAGE THERAPIST PE~tyIr[ C~,$~Q:OO ~,:
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ORIGINAL PERMIT CI RENEWAL Il~~ r U__'I!II)'\
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1. APPLICANT INFORMATION L Il J
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middle name
a.
_Q6\\ SCRU
last name
firstn&~
b, ~lloif:, ~"S\, ~,~
home address city
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IN
state
f(P'l-W
zip code
,-)' '.
r--\k
home Phlne no.
'd, r~~ S~()~to
business name
W(D~h"
supervisor (If applicable)
~17-044 - J.oLO
business phone h~.
c.
3rf ~ fo11o- cf6~~
alternative phone no.
tVolXcul.p@ ~~D# COJVL
email address
e. \'L.O ~, WMLl:w ,
"business address
QturMt.-l
W
state
4tob'Q L
zip code
city
2. APPLICANT BACKGROUND INFORMATION
a. ,I am eighteen years of age or older. 0 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 Titie 35 of the
Indiana Code. If yes, explain below.
~NO 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, r,evoked for cause by any governmentai 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 ~ES
'l!,9QfD7.
~(:l-1c ~'R oc\V'ik .~ ~~50( F1' rrt
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r
,
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. ". ~
i NO 0 YES Name of school I institution t\ ,j,,(II\O\\J IN' ~<,.-k -tk-ft Wt...o leMS)
b.
I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
~ YES
o NO
c.
I have attached proof of my professional iiability insurance of not less than $100,000 per occurrence an<!
$250,000 annual aggregate.
o NO
DYES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. ~ r lV'--1 0'M-if.aM.- ~i~~ ~"'-
year occupation business name
~1d@J\\\e. ~'N
city, state zip J
)10 - a:::o /
phone no.
~'.
year
"../
o >N-v\
occupation
((~~~tk~o-..
business name
fr~~ J 11'1
city, state zip /
817-- ~)~ -''-'00
phone no.
I
I
year occupation
business name
city, state zip
phone no.
c,
"
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
0-
I have received a complete copy of Carmel City Code Section 4-21
o NO
~ YES
State of Indiana )
) SSe
County of Hamilton)
I attest that all of the above information is true and correct to the best of my knowledge and belief. I un.derstand ~
that any materially false, misleading, or Incomplete statement on this Application shall constitute groui1ds for
denial of this ap 'cation and/or revocation of my Massage Therapist Permit.
~~p,-
Name printed
d and Sworn to before me this ?J I ~, day of _~ r " \ - '
), ..15+\1,- ~
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;J;tt~ e{ I\- ~, u-Uc
~5. 20 I
Signature of Appli
'fUU'SL\.l.-S
20 01-
. -
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My commission expires on
~
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