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HomeMy WebLinkAbout07100162 ApplicationC,Sy OF?CAJtAt" 0 '01 T City of Carmel "'-, +!?=tom. Department of Community Services 1 Civic Sq..-are, Carmel, Indiana 4802 31537] 2444 phone 311571 1499 1 ax APPLICATION - MASSAGE THERAPIST PERMIT - $20.00 A ORIGINAL PERMIT ? RENEWAL _.11I 1. APPLICANT INFORMATION a (-? i h ems' , A, i t,' - last name ors] name middle name b. "7 70S (:rV,'-L i 0l CT. F1 S 111i S1) - home address [? j city , 1 p state + zip code C. 21-2 - S 77-c-2 d / -I I -? " -?OI .?`70 ? jl'YrS S4?t2 ?1 G" Gf?PS. Cu' home phone no. alternative phone no. emari d. ??dssa rat Eh 1? y S1,P ?? eh ?? ?'7 S L1 C 3 business named supervisor it applicable; bus''inless phone no ^ 1 e. G/QGp w /O?n S! dGd C4 V {r"r? 1 : N business address dty state zip -ode 2. APPLICANT BACKGROUND INFORMATION a. I am eighteen years of age or older. ? NO mil YES b. Have you, within the past three (3) years been convicted, or plead Nolo Gontendere for any crime of unlawful deviate conduct, deviate sexual conduct or sexual conduct as defined in Title 35 of the Indiana Godc- If yes, explain below. gN© ? YES Dale liLocation1011ense c. Have you, within the past three (3) years, had your massage therapist's license or permit denied or revoked for cause Ly any governmental entity in the United States? If yes, explain below. VNO ? YES Date; Location! Reason d. Attached is a copy of my Limited Criminal History report, which was provided Torre by the Indiana Sta--e Police no more than shirty (30) days prior to the date en vinich I am submitting this application to the City of Carmel; ? NO A YES 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 off graduation. ? NO YES Name of school/ institution Kl? lOJ r- ?' /rr G e b. I have attached a copy of my diploma or certificate of graduation from an accredited school or institution of massage ? NO L3 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 W YES 4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS. a.?7 M t.T(,. sue h.asyc .,, frs4yr Y/Oj?l .0"lS?} hcna no. year occupation business na a city, state zip p f%OL b 4Ss6"? U?/ln C? ?olk)2 sse Zn? Say ?Pc C4 ?l1117 dsf «7 ?so? . year occupation busin=_ss name city, state zip phon=_ no. c. OS A-"tom. LeAA /r I C iGS I??Ic r'Y 1'nrt l^-oitA, l7i 3/ ?O year occupation business name city, state zip phone nc. 5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE I have received a complete copy of Carmel City Code Section 4-21 ? NO -U YES State of Indiana J ) 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 incomplem2statement on this Application shall constitute grounds for deni 42?r--- al of this application and;'or revo io my Massage Therapist Permit__.II Y('rfl Gf heS - Signa re f Applicant Name printed Subscribed and Sworn to before me this d 5i day of OC47. .200-7 ??awzca? h AML - Signature of Notary ?'A-m cu-h 6. LUX Name Printed My commission expires on V 'A 20_kT