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APPLICATION FOR LICENSURE AS A BARBER
State Form 1877 (R6 / 5-07) Approved by State Board of Accounts, 2007

STATE BOARD OF BARBER EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3031 Fax: (317) 233-4236 E-mail: [email protected] www.pla.IN.gov

INSTRUCTIONS:

1. Applications must be accompanied by the fee. 2. Attach one (1) 3 x 5 signed photograph on the bottom part of page 3. 3. Please type or print legibly.

* Your Social Security number is requested as stated in IC 4-1-8-1. Disclosure is mandatory.
The number will be given to the Indiana Department of Revenue. FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE LICENSED ISSUED (month, day, year)

DO NOT WRITE ABOVE THIS LINE

INFORMATION ABOUT THE APPLICANT
Name of applicant Social Security number

*

Address (number and street, city, state, and ZIP code)

Date of birth (month, day, year)

Residence telephone number

(

)

E-mail address

Have you ever applied for a certificate of registration to practice as a barber in Indiana?

If Yes, date of application (month, day, year)

Yes Applying for Licensure by:

No Endorsement Examination

INFORMATION ABOUT THE SCHOOL ATTENDED BY THE BARBER
Name of school Date of entry (month, day, year)

Location of school

Date of graduation (month, day, year)

Hours completed

RECIPROCITY APPLICANT (Application shall be accompanied by original or notarized copy of certification of license from state of licensure)
State of licensure License number Date of issuance (month, day, year) Date of expiration (month, day, year)

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If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. Letters from attorneys are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Have you ever been convicted of, plead guilty or nolo contendre to any offense, misdemeanor or felony in any state, or by the Federal courts, or any agency of the government, or are criminal charges now pending against you? (Except for minor violations of traffic laws resulting in fines) 2. Have you ever been denied a license, certification, registration, or permit to practice as a barber or any other profession in this or any other state? 3. Has any complaint been filed against you in the state of Indiana, or in any other state, regarding any professional license you currently hold or have previously held? 4. Has disciplinary action ever been taken regarding any professional license, certification, registration, or permit that you currently hold or have previously held? 5. Are you a registered sex offender?
VERIFICATION AND SIGNATURE

STATEMENTS

Yes Yes Yes Yes Yes

No No No No No

I do hereby certify and declare that I have not committed an act which would constitute grounds for disciplinary action under IC 25-7-16.1, that I will abide by and obey all provisions of the law and rules adopted by the board, and hereby swear or affirm, under the penalties of perjury, that the answers appearing hereon are true, complete, and correct.
Signature of applicant Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency or the State Board of Barber Examiners, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board, or any of its authorized representatives in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency and the State Board of Barber Examiners to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency and Board from any and all liability in connection with such disclosure. A photostatic copy of the authorization has the same force and effect as the original.
AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

NOTARY CERTIFICATE

STATE OF ___________________________________ COUNTY OF _________________________________

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SS:

I, ______________________________________________________________, first being duly sworn on oath say that I am the above named, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of applicant Signature of notary public

Printed or typed name of applicant

Printed or typed name of notary public

Date subscribed and sworn to notary public (month, day, year)

County of residence

Date commission expires (month, day, year)

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THIS SECTION IS TO BE COMPLETED BY THE BARBER SCHOOL ON BEHALF OF THE EXAMINATION APPLICANT.
CERTIFICATION OF TRAINING

I hereby certify that _________________________________________________________________ has completed fifteen hundred (1500)
(Name of applicant)

hours of training and has graduated from the _____________________________________________________________ School of Barbering.
Practical exam score Date of practical exam (month, day, year) Written exam score Date of written exam (month, day, year)

Signature of director/instructor of school

Printed name of director/instructor of school

NOTARY CERTIFICATE

STATE OF ___________________________________ COUNTY OF _________________________________

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SS:

I, ______________________________________________________________, first being duly sworn on oath say that I am the above named, that I have personally prepared the foregoing certificate of training, and that the same is true to the best of my knowledge and belief.
Signature of director/instructor of school Signature of notary public

Printed or typed name of director/instructor of school

Printed or typed name of notary public

Date subscribed and sworn to notary public (month, day, year)

County of residence

Date commission expires (month, day, year)

PHOTO

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