HomeMy WebLinkAbout07120003 ApplicationGlt y OF CA
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Department of Community Services 1 Civic Square, Carmel. Indiana 46032
317 571 2444 phone _117 571 2499 fax
www.carmel.m.a v 0 ja anDad
APPLICATION - MASSAGE THERAPIST PERMIT - $2
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?ORIGINAL PERMIT ? RENEWAL FNF% ? IJ 1911
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1. APPLICANT INFORMATION
By
a. STAZeU4' , -- EDWARD
last name first name middle name
b. 7CddD 5xM41JZN LAAf M ?ra9IAPA IN 4&237-92A
homeaddress city state zip code
G. s17-ss5 1172 31?--CyR-778[1 bob.ShlcV cS s}]gln,61.,icf-
home phone no. alternative phone no. emei address
Sltierry Keene
d. s5nce VV C61;?6r Alar5`h 317- 815-(x60
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business nom supervisor (if applicable) business phone no.
LrOW %J. le 5T. Sbf7E 2?
e. -?ykoencl- C?1rmt 1 IN q1v032.
business address Rr3. city slate zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older, ? NO XYFS
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. It yes, explain below.
XNO 0 YES Date! Lepaf uri l 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.
,ZCNO ? 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;
? NO YES
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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 was awarded my diploma or certificate of graduation.
? NO YES Name of school l institution ?_ ie ?rr.)T bmj o? As5iry
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
? NO Nr 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 JR' YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a. 2W A(1155W nWWi MayAGF GNWI IN %o31 317.815-"43
year occupation business name city, scale zip phone no.
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b.?m7 W,%sA(- 103TV+raR 6'1? re 4?uwn?s5 iM?l'cmfb(is, 11J q1 1-11
- 3[7.375-8O
year occupation 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 ? 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.
m 'R06€r E. WIS Q?
Signature of Applic nl Name pinned
Subscribed and Sworn to before me this 3 day of 1?eekA-Abek , 20_oj
Signatur-eToNo ary a K) Vr'j
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Name Printed'
My commission expires on / , 20LS