HomeMy WebLinkAbout07110089 Application1•
G
Ceit ®f Carmel
"- = Department of Community Services 1 Civic Square, Carmel, India 2g ? a U
JDIAL` ?' 317 571 2444 phone 317 571 2499 fax www.cannel.m. ?lllf LLC
APPLICATION - MASSAGE THERAPIST PERM - 4$0.00007
ORIGINAL PERMIT
? RENEWAL
1. APPLICANT INFORMATION 4 0-7 11C El. 'I 1411w00Gf 61?(??lt'?l 4.81 ?Ul?G4
last name first name middle nam
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.
'4NO ? YES Date i Location ; 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.
* NO ? YES Date; Location! Reason
b. ?6r' flrborW tt ni%Ona00j 1 JJ" y4Llo8
horse address city state zip code
c. (3)-7) 33;q- Izy-7 (3)-a) bqo-3)u I
home phone no. alternative phone no. mail address
d. S C AlhA, Ctzn-i-
business nam ' supervi; (t applicable) business phone no.
e.
business address city
state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ? NO ( YES
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;
? NO )k 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 of graduation.
? NO ? YES Name of school i institution
b. I have attached a copy of my diploma or cer•.ificate of grad ion from aria
institution of massage
? NO ? YES
C. I have attached proof of my professional liability insurance of not less than
$250,000 annual aggregate.
? NO ? YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3)
year c=upa5, n business name `•
b.
year
name
city. state
5est of my knowledge and belief. I understand
this Application shall constitute grounds for
slst Permit.
year occupation \\•? business name \\ \1 i\ state zip phone no.
5. RECEIPT OF MASSAGE THER\AP ST PERMIT ORDINANCE
I have received a complete copy of Car\hCity Code Section 4-21 ? NO ? YES
State of Indiana )
J SS: \.
County of Hamilton)
I attest that all of the above information is true and correct
that any materially false, misleading, or incomplete statem
denial of this application and'or revocation of my Massage
Signature of Applicant Name
Subscribed and Sworn to before me this day of
schoolor
per occurrence and
phone no.
phone no.
20
Signature of Notary
Name Printed
My commission expires
.20
w
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 o?her 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. J
? NO -1A YES Name of school/ institution $ S 16')11-d rY ?f J ,r 7. 61D ii)
{?yIF1Gn
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
? 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 p- YES
4. MY E LO ENT HISTORY FOR PAST THREE (3) YEARS.
a. ? 1• 'J H/ Till??P?S J..l1S?1t8nv- ?I(?rHnt7'd?? S 1T/ ??? D?r?"Zy??
year occupatlon business name city, state zi qta so phone no.
year cupation business name city, sate lip phone no.
year occupaficn business na city, state zip phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
have received a complete copy of Carmel City Code Section 4-21 ? NO YES
State of Indiana )
) SS:
County of Hamilton)
Signature o:71 z
?So1l ?r Lk.ilh•I+u)M6
Name anted
My commission expires on ) - ,'?' 2010
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
ZV, tal of this application and/or revocation of my Massage Therapist Permit.
/"i. 1 01'ben J 1wov.?
Signature of Applicant Nine printed
Subscribed and Sworn to before me this f day of 1 18?Q?1 200_?