Free 45243.FH11 - Indiana

APPLICATION FOR SALON LICENSE
State Form 45243 (R3 / 7-08) Approved by State Board of Accounts, 2008

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

INSTRUCTIONS:

1. Include the license fee when filing this application. Call or visit our website for current fees. 2. Do not file this application until the salon is ready to open. A temporary permit will be issued upon receipt of a completed application. The salon must be ready for inspection upon filing this application. 3. A change in salon ownership or location requires a new license. 4. Sanitary requirements indicated in the State Board of Cosmetology Examiners rules must be posted in the salon. 5. Salon license must be posted in the reception area of the salon and be visible to the public. 6. Cosmetologist, manicurist, esthetician, and electrologist licenses must be posted at their work stations and be visible to the public.

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it. Social Security numbers are available to the Indiana Department of Revenue.

FOR OFFICE USE ONLY
Date approved by board (month, day, year) Receipt number Issuance fee License number issued Date fee paid (month, day, year) Date license issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE
Type of license (please check one)

Cosmetologist

Manicurist

Esthetician

Electrology

APPLICANT INFORMATION
Name of salon Address of salon (number and street, city, state, and ZIP code) Name of owner(s) (indicate all owners) Address of owner(s) (number and street, city, state, and ZIP code) Telephone number of salon Telephone number of residence E-mail address License number of supervisor County in which salon is located Nearest highway number (if salon is located on Rural Route) Social Security number or Federal Identification number *

(

)

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Name of supervising licensee Location of salon

Business

Residential

Give specific directions to salon (exact location with respect to a residence or surrounding building):

Normal salon hours

Check days salon is open

Sunday
Is this salon connected in any way with residential living quarters?

Monday No

Tuesday

Wednesday

Thursday

Friday

Saturday Yes No

If yes, is the salon separated from the residence by a substantial floor to ceiling partition with a separate entry?

Yes
If yes, explain the nature of the separation:

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If the salon is owned by a corporation or partnership, list the name, title and address of the officers of the corporation or partners of the partnership. NAME TITLE ADDRESS (number and street, city state, and ZIP code)

CERTIFICATION I will operate establishment in compliance with the rules governing the sanitary requirements of salons as required by the State Board of Cosmetology Examiners, and ensure that all employees comply with all requirements. (If salon is owned by a corporation or partnership, this application must be signed by an officer of the corporation or a partner of the partnership.) The salon will be under the personal supervision of __________________________________________, license number _______________________________, expiring ________________________, who has the required active experience.
Have you or any owner, partner, or officer ever committed an act for which you could be disciplined under IC 25-8-14? If yes, please describe the act on a separate sheet of paper and attach to this application.

Yes

No

I certify that I personally completed this application and that the information appearing hereon is true and correct to the best of my knowledge and belief. I understand that providing fraudulent information may be grounds for refusal to issue the license or for disciplinary action against the license after issuance.
Signature of applicant / corporate officer / partner Printed or typed name of applicant / corporate officer / partner Date (month, day, year)

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