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HomeMy WebLinkAbout07110085 Applicationfit of C.'arynel Department of Community Services 1 Civic Square, Corral, Indiana 4(M2 317 571 2444 phone 317 171 2499 fax www,carrn in,go, APPLICATION - MASSAGE THERAPIST PER ? ORIGINAL PERMIT ? RENEWAL N0? 1. APPLICANT INFORMATION a. l? e `. is last Sr Male I firstname middle narr,e ,!r b. ??fCvl.tgr?' ?lf'Td0..? ?j?Jc4?fr r?A,c d ? 4a" 7? Z`? hone addre city slate zip code r7 ?S `f°99 ??elewrsZ?az??ak home phone no. alternative phone no email address d. 1 ` bueine 'ame U supervisor tit applicable) business pnoneno. e. business address city state zip coca 2. APPLICANT BACKGROUND INFORMATION a- I am eighteen years of age or older. ? NO S YES b. Have you, within the past three (3) years been convicted, or plead Nele Contenders for any crime of unlawful deviate conduct, deviate sexual conduct or sexual conduct as defined in Title 35 of the India a Code. If yes, explain helow. 0 ? YES ©ate I Location! Dttense 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. VA No ? YES Date i 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 t am submitting this application to the City of Carmel; ? No U/YES O.C0110 \ 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 certific to of gradu474041V attiiion ? NO Sit YES Name of school; institution 'I- b- I have attached a copy of my diploma or certificate of graduation from an accredited school or institution of massage ? NO assYES C. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and $250,000 annual aggregate. ? NO 2/YES 4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) Y ARS. a Wit ?(Q6fxua gu?Zf &wJT, bo32 t7 ?!X) yea occupation business name city, slate zip phone no. b. year occupation ousiness name c. year occupation business name city. state zip state phone no. phone no. 5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE `/ I have received a complete copy of Carmel City Code Section 4-21 ? NO U1 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. l 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. 61 ft, t t"64? js ?A 4cU3 Signature of Applicant Name printed ?p?,,, Subscribed and Sworn to before me this day of W r ? I bx- , 2007 Sure of NoIn" Awi,A- Name Printed My commission expires on T - a1) , 20T L