HomeMy WebLinkAbout08020028 Applicationof CAJ?Af t
Ci'ty of Carmel
Department of Community Services 1 Civic Square, Carmel, Indiana 46032
NDl'??1`??' 317 511 2444 phone 31? 571 2499 fax www.carrnel.in.gov ?Z
APPLICATION - MASSAGE THERAPIST PERMIT - $20.00
? ORIGINAL PERMIT ? RENEWAL oooo 1
i. APPLICANT INFORMATION
a,
last name
ff6iVU)n
middle name
? ?j A Pe w b. l2-? 0 1 Y?fll'? h l1 1?'$ttd Ll
home address city ?- stale zip code
home phone no. alternative phone no.
d. Qlf'V-`d
business name
e. ( ?Q r c?
business address
0
supervise N applicable) busines`slphone no.
?afmd N tI C 2
city„ state zip code
2. APPLICANT BACKGROUND
C.
a. I am eighteen years of age or older. ? NC %421 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
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,
NQ ? 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;
? NQ YE8
k
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 M ct -Fir N C 01
b. I have attached a copy of my diploma or certificate of graduation from an accredited school or
institution of massage
J NO l1V 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 FOR PAST THREE (3) YEARS.
a. I f I S Fc fat7-?tblc
year occupation business name city, stale zip phone no.
c'7&
b2![2 ' OL c l A' I7,
year occu ?+ 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 0 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 this application and/or revocation y Massage Therapist Permit. ` -
1
a-?M , L.A ( I Y-y"I
0 CH
Signat re p ican Name p nted
Subscribed and Sworn to before me this (n day of 4u-b 20 C,6
_Rma-a- V?-?
Si nature of Notary km LAL L?Lk
Na a rimed
My commission expires on
2ZCp