HomeMy WebLinkAbout07110051 Applicationor CA114e? ® D R 2 T 6 T T
City of t
e Ca, Department of Community Services 1 Civic Square, Carmel, Indiana 46032
-WD IATA 317, 571 2447 phone 317 571 2499 fax www.cazmel.in.gov
APPLICATION - MASSAGE. THERAPIST PERMIT - $20.00
)(OHIGINALPERMIT I7 RENEWAL -#,- 6-7) f OC6
1. APPLICANT INFORMATION
a. -?rJ IAA ?? i7D
lgast2ame first name middkename
b. IN
I 1?G lO ?}uE?Ltytlt V I? Y17?L ?
home address city state zip code
home phone no. alternative phone no. email address
d.
business name supervisor (if applicable) business phone no.
e.
business address
stale zip code
ne i-
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
Indiana Code. If yes, explain below.
*NO ? YES Date i 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.
?IvO 13 YES Date I Location l Reason
d. Attached is a copy of my Limited Criminal History report, which was provided tome 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 AYES
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 l YES Name of school /institution ?0i 4r14 10 ?-LE6e ml & D( ile
GDF?I 11 Ej
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-
Q NO YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a.
year occupation business name city, state zip
b.
year occupation business name city; slate zip
phone no.
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 infomration 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.
Sig tuA Name printed
k plc
S crib and Sworn to before me this day of I V(?1tP/Y11 Up/ -,20d-7
Signature of Notary
TA rn -P-1
Name Printed`
My commission expires on?r?.5 , 20 I S