HomeMy WebLinkAbout07080249 Application.? OF CAR4f
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IN'DIANS`
City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032 f
317 5712444 phone 317 571 2499 fax w .carmeldn.gov
APPLICATION - MASSAGE THERAPIST PE
? ORIGINAL PERMIT ? RENEWAL 11D? ff 0 ( IC
1. APPLICANT INFORMATION
a. VEP UA7?1'2 Ct /-I /l S
last name first name middle name
b. 1166,0 city?;1,a2A 9PC)/ / I N A/Z 92
home address state zip code
?• -?i 7 59,g ? 3539 3/Z X79 0719,4 to-& grfl?lwrrz:a ?L
home phone no. - alternative phone no. email address 40 L , C
business name supervisor (if appale) buslness phone no.
e. ? ?n Adrr¢n n cr gZ ,7n <'A2tis'l _ !Xt3 ?.-.
business address city s to zip code
2. APPLICANT BACKGROUND INFORMATION
a. - I am eighteen years of age or older. ? 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
Indian ode. If yes, explain below.
NO ? YES Date / Location / Offense
C.
Have you, within the past three (3) years, had your massage therapist's license or permit denied
or rev ed for cause by any governmental entity in the United States? If yes, explain below.
NO ? YES Date / Location 1 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 Car
? NO LN YES
07 CCL&d o?C HL> j>" T
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.
? - NO " L71 YES Name of school / institution ( J 8141 -f A S A 6 LF 7-J7 i2& A OZ
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of mass
? 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.
? NO YES ? (w t 0 -? NIbz-Y
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a NSF ti
pOa.- f'2 T/felLd F nr???n Ae?5?1??/n A/L???,i?l dG3
year occupation business name city, state zips- phone no.
? /7 gyy- 666 b.-
year occupation business name city, state zip phone no.
C.
year occupation business name city, state zip phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21 ? NO 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. 1 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.
Signature of Applicant Name printed
Subscribed and Sworn to before me this 30 day of 20Q-j
Signature of Notary -l ,-M e`,- lei . L ?Lx
Name Printed
My commission expires