HomeMy WebLinkAbout08010009 ApplicationO?Y OF CAIII
-4 1
F
I!?; DIA'`??`
•
Carmel
City of
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
317 5712444 phone 317 571 2499 fax www.carmel.in.gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
a ORIGINAL PERMIT
? RENEWAL -#-- C)SOI Ocoq
1. APPLICANT INFORMATION
'Dn -15
a. +? W f
last name first name middle name
b.?
home address city state zip code
w .., .... .'.i y c.'t f ? nr+tr 8 N cc.? / • t a.v?
C.
home phone no. altemative phone no. em address
d. 445dl rSIr iRAC !s/i ?T ,PV-?0
business name supervisor (if applicable) % usiness phone no.
e. zL &eco77?? AfA r ??y*c o j Z - 4w4- business address aty state zip code
2. APPLICANT BACKGROUND INFORMATION
a. I am eighteen years of age or older. ? NO Q'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.
GdrNO ? 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.
IJ('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 date on which I am submitting this application to
the City of Carmel;
? NO DYES
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 I institution f'f/U4K4( d 4co/d.a LjL4!/?G
???rL?l.BI/j7'GS ?ivG • ?A.?X 28?' /.J
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or 116a0r
institution of massage
? NO UYES
c. I have attached proof of my professional liability insurance of not less than $100,000 per occurrence and
$250,000 annual aggregate.
? NO lad YES
4. MY EMPLOYMENT HISTORY FOR PA??S////T?THREE (3) YEARS.
year 4pVn business name city, state vp phone no.
year occup on ' business name city, state p phone no.
C. i 1 / CK ? o& na-vza
a r occupa business name city, s to zip phone no.
5. RECEIPT OF MASSAGE THERAPIST PERMIT ORDINANCE
I have received a complete copy of Carmel City Code Section 4-21 ER( 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 his applicafio nd/or revocation of my Massage Therapist Permit.
A rc X ? J o war
Signata"f Applicant -game printed
and Swom to before me this __I day of =hAL&U-Ak , 20 C)-?
'T 6
Signature of Notary
AAILLA L
Name Printed _
, 20
My commission expires on L