HomeMy WebLinkAbout07100180 ApplicationL? l? LC u u Ls
OF CA
11149t
1.1
IND1 A'W1
CitY of Carib
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
317 571 2444 phone 317 571 2499 fat www.carmel.in.gov
OC T 2 6 2007
APPLICASION - MASSAGE THERAPIST PERMIT - $20.00
ORIGINAL PERMIT ? RENEWAL
1. APPLICANT INFORMATION
a. \A/rlp?? -3 zcaw.,-? , lsc ic.. N\ C &-v1
last name first name middle name Q
b. 303 Cam. So.cksors Mwlber : W I?j "!6,056-01 o5
home address city ( , , state zip code
765-2976-22oq 765-LlOq-7-7 10 00
home phone no. alternative phone no. email dress ?Q •CCA
,4EEA -- SKerr K -e^e- 31 -8?b-o6co
d. Mas
business nam supervisor f plicable) business phone no.
e. IatSD-l0 Gfew?veranaPa55 Co Time-I IN Y6033
businesses 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
Indi Code. If yes, explain below.
NO ? YES Date / Location! Offense
c.
Have you, within the past three (3) years, had your massage therapist's license or permit denied
or r oked 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 tome by the Indiana
State Police no more than thirty (30) days prior to the date on which I am submitting this application to
SCANNED
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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 awarded my diploma or certificate of 1graduation. 11
? NO YES Name of school /institution F 1 o i' f OG ne-tenpo 1 t'FQn U 11i V
Y1ooSo?tti P .-,? c.na<e?L eeP
nr(onbo FL329tc1
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of mas e
? NO 7S
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual gregate.
? NO VYES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
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5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21 Zk) YES
State of Indiana )
) SS_ 3o6-08-5940
County of Hamilton)
I attest that all of the above information is ue and correct to the best of my knowledge and belief. I understand
that any materially false, misleading, r r mplete statement on this Application shall constitute grounds for
denial of this applig9tion aqd/o?evV gff my Massage Therapist Permit.
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Name printed
gibed and Sworn to before me this ,day of L/u 20 0
Sigs?ot Notary
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My commission ezpir`,es„on. L:??y