HomeMy WebLinkAbout07080240 Application1S.y OF CA
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City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
317 571 2414 phone 317 571 2499 fax www.carmel.m.cov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
M/ORIGINAL PERMIT ? RENEWAL
1. APPLICANT INFORMATION
a. DENkRToiD DCBKAt 5FAtQ
last name first name middle name
b. 59(08 WORM BILC PLACe C P-MEL I /) 14,033
home address city state zip code
c. 3)-7 -,51 1-889 in-37/-333S` MsoLUT-1ONSU-CQAQLC"
home phone no. altemative phone no. email address
d. MAssA66 Sot unolJS,WC SF -GMPLOYE9 317- 3 71 - 3335
business name supervisor (if applicable) business phone no.
e. 570 N0l5)/-L PLACE CA-KMa- / %1,103T
business address city stale zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ? NO 5r 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.
2 NO ? 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.
YNO ? YES Date! Location / Reason
d. Attached is a copy of my Limited Criminal History report, which was provided to me by the Indiana
Slate Police no more than thirty (30) days prior to the date on which I am submitting this application to
the City of Carmel;
? NO Mr/YES
,? l5 o /o7 Cn_Q" -Vo- Jl
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 stale 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.
? NO a" YES Name of school / institution EAST1JE51 COLLE?oE CF 146,V-1A16 Ak'rS
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
? NO M YES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
? NO M YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
aopR- MASSA(;e
a.900'L THeAAPIS - MASSAGE SOWTIONS, 46C C?}KMCL-?/n? yGk3? 3i??i-?P9P
year occupation business name city, state zip phone no.
b.
year occupation business name city. state zip
C.
year occupation business name city, state zip
phone no.
phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21 ? NO W YES
State of Indiana )
) SS:
County of Hamilton)
I attest that all of the above information is true and correct to the best of my knowledge and belief. I understand
that any materially false, misleading, or incomplete statement on this Application shall constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
() I t L 411.JU a-" DCB KP? 3-- ?)E k Wbrrj
Signature of Applic Name printed
Subscribed and Sworn to before me this 9,;Z V0 day of sil f 2001
f
OFFICIAL SEAL
ERIKA LOUISE HAVERSTICK k U
NOTARYPUBUO-1111) A Si ure of Notary
MADISONCOWN
.. V/ OWW IEVirW Da I& M14 CYi?-A L
My commission expires on I?P_E P otib ¢? 20_L