HomeMy WebLinkAbout07120020 Application
Gl`1 OF CAP o
City of Carmel
Depar•.meni of Community Services 1 Civic Square, Carmel, Indiana 46032
tA DJ AIN' 317 571 2444 phone 317 571 2-99 fax wwvtcarmel.in.gov
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APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
? ORIGINAL PERMIT
? RENEWAL
1. APPLICANT INFORMATION
a. C?oy` 1?PAYll1Cn 0, r k e- Vle
last name first name middle name
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b.
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home address ciP/ slate zip code
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home phone no. alternative phone no. email address
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d.
business narri supervisor (if applicable) business phone no.
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.
business address civi state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ? NO [d' 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.
V 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? If yes, explain below.
0 NO ? YES Date i Locamn i Reason
d. Attached is a copy of my Limited Criminal History report, which was prdvided 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 4 YES
8?66 157(19
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 v.,as awarded my diploma or certificate of graduation.
? NO 'W YES Name of school !institution 'r'QkQ An Cb119- e
v
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
? NO ff 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 V- YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a.
year occupation business name city, state zip phone no,
b.
year occuparion 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 J
) 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
deco of this application and/or revocation of my Massage Therapist Permit.
'7 .,-t na- ? eh l " ? p Gh? Ott
Jic ature of i.pplicant PF1ame ?riWcd nted
Subscribed and Sworn to before me this 5 day of. be , 200'7
Si ature ncnf Notary
Name printed
My commission expires on 20 l?