HomeMy WebLinkAbout08010007 Application- "zt .
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City Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
? DIA?P` 317 571 2444 phone 3] 7 571 2499 €ax www.carmel.in.gov ? 0001
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
$1 0RIG9NAL PERMIT ? RENEWAL OCCN
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1. APPLICANT INFORMATION JAN D 4 K08 ? ll
a. 1 +?
Last n e first name
b. ?54 W N
home address city state zip code
home phone no. alternative phone no. email ddress
d. 5M, 01 fU t6y- (.6,y C-V l 3J j 9C) D r
business name supervisor if app icable7 business phone no.
business addre city state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ? NO ?f-l'ES
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.
ZkO ? 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.
NO ? YES Date ! Location ! 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 dale on which I am submitting this application to
the City of Carmel;
? NO 1. YES
SCANNED
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 ! institution ' V T L? I
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
? NO R, 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 W( YES
4. MY EMPLOYMENT HISTORY FOR PAST THREE (3) YEARS.
a-05--D-+
year occupation business name city, state zip phone no.
b. 05-t e--m WdLU'a W -t`S (k ` w1d) 3o -7053MT
year "occupation business name city, stat 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 421 ? NO 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. 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.
Signature of Applicant Name printed
// Subscribed and Sworn to before me this 0 day of 20 Ofd'
0
Signature of Nota
Q Sir/ ??i51
Name Printed
My commission expires on D2'? '206
SCANNE