HomeMy WebLinkAbout07110177 Application1&-•q OF Cq
GK'S R4f,l
City of Carmel
<da
Department of Community Services I Civic Square, Carmel, Indiana 46032
4NDIAlN?'
317 571 2444 phone 317 571 2499 fax wutiv.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
.ORIGINAL PERMIT ? RENEWAL -f,- c711 017-7
1. APPLICANT INFORMATION
a. f - W.616A er
Tasesame first name middle name
b. 9993 F11s P .0. _7-A( 443s.
home address city state ap code L, e16 dome phone no. altemadve phone no. email address
d. ?Nv
siness name supervisor (f applicable) business phone no.
/fJQt? l?1 l oo ?X Me/ ?- tllcQ3 ?-.
business address city I state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ? NO P-rES
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.
,0'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.
?--?0 ? YES Date I 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;
10 NO Qa YES
vcw15V7
3. MY QUALIFICATIONS:
a. 1 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 1 "IFF,q??(A??rn? 11I??1I( 1?/
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
? NO I.7 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 ;d YES
4. MY EMPLOYMENT HISTO Y FOR PAST TH EE (3) YEARS. r
a. o TJ` 6
?Dr occupation usiness' ame city, st .e zip ! phone no.
b.
year occupation businerss name city, state zip 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)
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 ppiication and/or revocation of my Massage Therapist Permit.
0_?Q 1 ?l bt?,ir'CCl lfSh??t/ilC?t111f?
10
Signatureof P.pplloant Name printed ,p I,,?
Subscribed and Sworn to before me this day of U/)1 bPA , 2e
? XL? f
Slgr a'ture of Notary
Name ring
My commission expires on '? , 201 S