HomeMy WebLinkAbout07110171 ApplicationOF CAkif o
of Carmel
_ City
w u
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
INDIAN?'
317 571 2444 phone 317 571 2499 fax caw .carmel.in.gov
(? (? TION - MASSAGE THERAPIST PERMIT - $20.00
Uu L, I? V 'TO THE ORDER OF
RIGINAL PERMIT ? RENEWAL TH THIRD BANK
nV 2 9 2007 R DEPOSIT ONLY
- rn MKAFI
0-7110 -7 1
999-93427
a. -1? -'(Ylrnt? 4--??CL Yu-k-b (eel
last name fir ame middle name
b. bg 1 ?'D M6Q1\;4 UicP,4 ?4 A
ho l?
me address city state zip code
c. I1-32?-1? 1y -- r-bmrr)-n - c
home phone no. alternative phone no. email address
d. Rg- -C
business name supervisor (if pplicable) business phone no.
e. ?OCYJ W ,1ula"-'gar t Caf Mel -T-t1 `4lQ 032
business address city state zip code
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.
Ml NO YES Date/Location/Offense
cl('A
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.
?14 NO ? YES Date 1 Location I 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;
? NO VYES
bbbb
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 / institution RYY1GY ?C-C r K c?
b. I have attached a copy of my diploma or certificate of graduation from an accredited' school or
institution of massage
? NO 'W 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 ?1, YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. P?aSk+gQ m{1 }?Y? olty, Cal Les?z ?? GYto?Gl sN all- lo1J-? 3S 3
year occupationsr?t- busine name city, stale zip 46214 phone no.
b.
year occupation
c.
year occupation
business name
city, state zip
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 -?g 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. 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.
( '?trY ?? um 4? ?yV? C? ?'TN l?ct \?, T rn e_rS
SignahWe of Applicant Nattle printed
Subscribed and Sworn to before me this a q day of I?l t?ml 2007
AWL
Signature of Notary
? ?L l? . Lct,?C
Nance Prin ed
My commission expires on ly , 20-JY
phone no.