Free 51774.FH11 - Indiana

AFFIDAVIT OF COMPLETION OF ADDITIONAL HOURS OF INSTRUCTION
State Form 51774 (R / 6-08)

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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.IN.gov/pla

* 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.

Type of instruction (please check one)

Cosmetologist

Manicurist

Esthetician

Electrologist

Instructor

AFFIDAVIT Pursuant to 820 IAC 2-2-5, 820 IAC 2-2-6, 820 IAC 2-2-7, 820 IAC 2-2-8, 820 IAC 2-2-10, and 820 IAC 2-2-11 of the rules of the State Board of Cosmetology Examiners, this is to certify that :
Name of student Student Social Security number *

has satisfactory completed additional instruction in theory and practice at:
Name of school License number of school

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

Date of enrollment (month, day, year)

Date of completion (month, day, year)

Number of hours completed

I hereby certify and declare that the above stated certification of training to be correct and accurate record of the student enrolled at the school of cosmetology named above and meets the requirement of the State Board of Cosmetology Examiners and that I personally completed this affidavit. I understand that providing fraudulent information may be grounds for disciplinary action against the license of this school.
Signature of school official Date of signature (month, day, year)

Printed name of school official

NOTARY CERTIFICATE STATE OF INDIANA SS COUNTY OF ________________________

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)