Free 51771.FH11 - Indiana

AFFIDAVIT OF COMPLETION OF ONE HUNDRED FIFTY (150) HOURS OF INSTRUCTOR TRAINING
State Form 51771 (12-04)

Indiana Professional Licensing Agency 302 W. Washington St., Rm. E034 Indianapolis, IN 46204-2700 Telephone: (317) 234-3031

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1. It is mandatory that it be given. Social Security number are available to the Indiana Department of Revenue.

AFFIDAVIT

Pursuant to 820 IAC 2-2-6 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 an additional (150) hours of instruction in the theory and practice of instructor training at:
Name of school Address (number and street, city, state, ZIP code) School license number Signature of school official Date enrolled (month, day, year) Date completed (month, day, year) Date signed (month, day, year)

I herby 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 below, and meets the requirement of the State Board of Cosmetology Examiners.
Name of student Name of cosmetology school Signature of school official Printed name of school official

STATE OF INDIANA COUNTY

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SS:

Subscribed and sworn before me on this __________________________ day of __________________________ , 20 __________ .

NOTARY CERTIFICATE
Signature of Notary Public

Printed name of Notary Public

Notary county of residence

NOTARY SEAL

Notary commission expires