Free 49638.PDF - Indiana

APPLICATION FOR ACTIVATION OF A COSMETOLOGY PROFESSIONAL LICENSE
State Form 49638 (3-00)

INDIANA PROFESSIONAL LICENSING AGENCY 302 W. Washington Street, Room E034 Indianapolis, Indiana 46204 (317) 232-2980

INSTRUCTIONS: 1. Complete the entire form. 2. Attach copies of your certificates of completion for sixteen (16) hours of continuing education. APPLICANT INFORMATION
Name of applicant License number

Resident address (number and street, city, state, ZIP code)

Telephone number ( ) Date (month, day, year)

Signature of applicant

APPLICATION FOR ACTIVATION OF A COSMETOLOGY PROFESSIONAL LICENSE
State Form 49638 (3-00)

INDIANA PROFESSIONAL LICENSING AGENCY 302 W. Washington Street, Room E034 Indianapolis, Indiana 46204 (317) 232-2980

INSTRUCTIONS: 1. Complete the entire form. 2. Attach copies of your certificates of completion for sixteen (16) hours of continuing education. APPLICANT INFORMATION
Name of applicant License number

Resident address (number and street, city, state, ZIP code)

Telephone number ( ) Date (month, day, year)

Signature of applicant