HomeMy WebLinkAbout07120022 Application
City of Carmel
Department or Community Services i Civic Square, Carmel, Indiana 45032
317 571 ?444 phone 317 571 2499 fax www., armel_in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
L?J ORIGINAL PERMIT ? RENEWAL
1. APPLICANT INFORMATION
a. M? /2I1 7y A , /)Xi//,o Dy/lf1C-l2
last name first name middle name
b. J10 ?v?rJ9n'S-r?&7 JtN4J4&4100",( /,101,4&4 411
home apdre=_s city state zip code
3179z00:7 dr72582591,?/fjyahaa.c0M
home phase no. allernalive phone no. email address
d If assA&t divvy tu.F ,tOtTra J179X604 oa
'cusiness name supervisor (it applicable) business phone no.
a. /9.s0 C-,rF V& ! RSS l ?fl /L,tIEL /N J4/I?ia V6 1) 33
'cusiness address city state zip code
APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ? NO YES
Have you, within the past three (3) years been convicted, or plead Nolo Contendere for any crime of
unlawful deviate conduct, deviate sexual conduct or sexual conduct as defined in Title 35 of the
Indiana Code. If yes, explain below. II
LI NO Q YES Date i Location i Offense m1A
c. Have you, within the past three (3) years had your massage therapist's license or permit denied
aorrrr/eyaked for cause by any governmental entity in thelited states? If yes, explain below.
L'7 iV0 ? YES Gazei Location/Rea=.on / /A
J. Attached is a copy of my l Criminal History report, which was provided to me by the Indiana
Slate Police no more than thirty (30) days prior to the date on which I am submitting this application to
the City of
? NO i C (1577
J_
3. MY QUALIFICATIONS:
a. I am a graduate of a school or institution of massage therapy which is accredited by the Indiana
Commission of Proprietary Education or similar state agency or commission of a state other than
Indiana that required my successful completion of at leas: five hundred (500) hours of supervised
instruction before was awarded my diploma or certii#iv/c}ate of graduation.
'? No YE$ Name of school i'insfitution / ?f?.SSr???? OAJEiU IAIS717L17Z
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
? NO YES
C I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual a gregate.
? NO YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
mAssh6IC
a M V7 TtMA1JPId7 MXJ5Alc- FNI/y Cie/NFL, 11V/J1RNA 31 7816 060 0
year cccupafcn business name city, etate'zip phone no.
mRSSAGE 7PE
6 2006 7NERknrs7 Xoi i DAy J)PA CA/c1t EC, /,voifiM1A >17 7o61300
year cecupatien business name city, state zic phone no.
14qfsAGE
c. 20 as 7NE FPl F7 ?M-10V ?UPr 2/A ?k 2flWOl+? ?NO/A>vA 3/765 2,8 Q Q
year cccupation business name city, state zip phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE 2/ 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 ail of the above information +s true and correct to the best of my knowisi and belief. I understand
that any materially false, misleading, or incompiefe statement on this Application shall constitute grounds for
iden oft ' ation and/or revocaon of my Massage Therapist Permit.
Diu/a ? 1' l?-.mod??TTHEI2
i Ft a cent Name rimed - ?j
sc ibad and Sworn to before me this ?L_?_ ay of I ??j 20?J
f[
icnatu s of NotLry
Na e Printed T
My commission expires on r:]j 20 0