HomeMy WebLinkAbout07120002 Application
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INDIANP'
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
Id ORIGINAL PERMIT ? RENEWAL
City of Car
Department of Community Services I Civic Square, Cannel, Indiana 46032
317 571 2444 phone 317 571 2499 fax
1. APPLICANT INFORMATION
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a.
last name -
first name middle name
b
llal,w C r.?oble filler 1 L1 9606Z
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home address aty _
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state zip aide
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C.
h e phone no. alternative phone no. email addmss
d. RU-SS Xiit ?/J\ Y 3 l-7- - O 163 -
business name supervisor (A applicable) business phone no.
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.
L7 NO ? YES Date / Location / 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? It yes, explain below.
L2 NO ? YES Date / Location I
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 J YES
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C-O-Q.et -10 0.6 in U->_ fy1112G? Garr?
G'6 Nowta- Qb Ott-
www.carorel.in.gov
3. MY OLIALIFICATIONS:
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 cerCrficate,off graduation. j?
? NO I"J YES Name of school l institution /a/101 TkeY'C1 L /' ((LASi'?.Q[r'+
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b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
? NO O'?'YES
C. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual a regale.
? NO Ul YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a.
year occu on business name city, state zip phone no.
b.
year c pabon business 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 2 '-*'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. t understand
that any materially false, misleading, or incomplete statement on this Application shall constitute grounds for
denial of Ffhis application and/or revocation of my Massage Therapist Permit.
0I1 I- l, ? I d l /. 1 1., 1. I
Sig u e of Applicant i Name printed
Subscribed and Sworn to before me this ?7 4-day of ??, 20 01
Lyn K. LaPrees, Notary PublIC
_ Co. of Residence: Marion n
_ Commission Expires: 8.13-2008 ( flyU-G?A.2J??
signature of Notary
. --_ .. LAN K ?,4P/LCseS
Name P'nted
My commission expires on 20