HomeMy WebLinkAbout08010128 ApplicationC' OF'CA44 t
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C ?ND1Al`??` :? 0 ?gc 16 1 ?'%,
ity of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
317 57 t 2444 phone 317 571 2444 fax www.cnrmeiJn-gov
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
ORIGINAL PERMIT ? RENEWAL OLirr J-71
1. APPLICANT INFORMATION
a. f?06 Y t5 Ml C aSN A w ?n t?_
last name first name middle name
b. it) ? -l G. 134 ON ?? ?? k?ear I
home address city stale zip code
91o - 0 4Ucl
lkorr-e pal vne no. aloe ve phone no. email address
d. ~)0.V Ct C M1? ` 3 I-7 tc ?c Z
business name supervisor (if applicable) business phone no.
e. 14 ?39 Q C .tj ?e?` r ,? c C ? ? Cyr w E d / a! c] L_
business address city state zip coce
2. APPLICANT BACKGROUND INFORMATION ti a. 1 am eighteen years of age or older. El NO 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.
* NO ? YES Date i Location ? Offense R
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.
4 NO ? YES Date r 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;
;a -
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. I f "?I i
? No YES Name of school ! institution A It Ax V1rti St h Q ? o l ? Af N
b- I Pave 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
$250,000 annual aggregate-
No ? YES
4. MY EMPLOYMENT HISTORY
-lFOR PAST THREE (3) YEARS.
a. 0}Z--cc?D_ ?u ? L„ A) L, ?, X100 ? 3y7 }?$ td ?
year accupali?T business name city, state' zip plr-one no.
???',-n4.ccup ? d-
year r business name city, state zip phone no.
c,oS-o? truce ,, Q 0kti- [ CJoCp; IMU-tA-(ei+t ((745 _ -, A ,
year occupal n business rare 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 0 YES
State of indiana I
) SS:
County of Hamilton)
I attest that all of the above information is true and correct to the best of my knowledge and belief. 1 understand
that any materially false, misleading, or incomplete statement on this Application shail constitute grounds for
denial of this application and/or revocation of my Massage Therapist Permit.
Signature of Applican! Name printed
Subscribed and Sworn to before me this j day of 2C::'Signature of Notary K-
?A v ))L- L- t7 L
Name Printed
My commission expires on L•? ?- ? .?, 20 4 ..s
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