Free 47401.PDF - Indiana

AFFIDAVIT - CERTIFICATE OF USE
State Form 47401 (12-95)

I hereby certify and affirm that the tanning device(s), serial number(s) _________________________________________________________________ , located at _______________________________ , __________________________________ , Indiana
(name of facility) (city)

______________________________ is / are exclusively for myself and my immediate family. I
(ID)

understand that should anyone, other than immediate family members, be allowed to use the device(s), that the Indiana Professional Licensing Agency has authority to impose Civil Penalties of up to one thousand ($1,000.00) dollars per occurrence. I further agree that this tanning device or any other tanning device that possess or operate, will not be offered for use by anyone, other than immediate family members, without first obtaining a License from the Indiana Professional Licensing Agency.
Signature of owner Date (month, day, year)

Signature of State Inspector, Indiana Professional Licensing Agency

County