Free 47266.FH11 - Indiana

AFFIDAVIT COMPLETION OF TWO HUNDRED FIFTY HOURS OF BARBER INSTRUCTION
State Form 47266 (R2 / 6-08)

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STATE BOARD OF BARBER EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3031 www.pla.IN.gov

Pursuant to IC 25-7-1-5 (4) (b) of the Indiana Barber License Law, this is to certify that

________________________________________________________________ satisfactorily completed an additional two
(name of student)

hundred fifty hours of instruction in the theory and practice of Barbering at ______________________________________
(name of school)

___________________________________________________ School license number __________________________
(address of school)

Date of enrollment _________________________________ Date of completion ________________________________
(month, day, year) (month, day, year)

_________________________________________________________________
(signature of school official)

I hereby certify and declare that the above stated certification of training to be a correct and accurate record of the student enrolled at the school of barbering named below, and meets the requirements of the Indiana State Board of Barber Examiners. I understand that providing fraudulent information may be grounds for disciplinary action against the license of the school.

(signature of student)

(signature of school official)

(name of barber school)

(printed name of school official)

STATE OF INDIANA COUNTY OF ________________

SS SEAL

Subscribed and sworn to before me this ____________ day of ________________________________ , __________ .
Signature of notary Printed name of notary

Notary's county of residence

My commission expires (month, day, year)