HomeMy WebLinkAbout07110045 Application
City of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
31? 571 2444 phone 317 571 2499 fax www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PER t Ohvb Q?
>?ORIGINAL PERMIT O RENEWAL NOV 9 2007
FORMATION
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1. AP V
PLICANT IN
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. lastname fir "n me middle narne
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b. home adcress city state zip code
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e. alternative phone no. email addre s `
home ph ne no.
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super&or: pplicahl
business namV
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business address city state zip code
2. APPLICANT BACKGROUND INFORMATION
? NO )YES
e or older
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a .
een years o
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.
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
ana Code. If yes, explain below.
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39 o ? YES Date! Location l 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
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;
'
?qeYES
? No
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 -.hat required my successful completion of at leas. five hundred (500) hours of supervised
instruction before I was awarded my diploma or certificate of graduation.
? NO YES Name m school 1 inslibution W es\-err\ Crs fv-' rr `c4e' 1
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. I hW4,` T N5A1r0x"'- / 1 1 Q 1 ? ?-
NO ? YES
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4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS. S c?
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year cccupalio ?in ess{? ame'J C_ city, state zip p phone no.
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year occupation nbusiness name city, state zip? phone no.
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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 O NO YES
State of Indiana )
) SS:
County of Hamilton)
1 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.
Signature o` plicant Nam ted
Subscribed and Sworn to before me his day of
20
Signature of Notary
Name Primed