Free 49529.PDF - Indiana

APPLICATION FOR COSMETOLOGY CONTINUING EDUCATION INSTRUCTOR
State Form 49529 (R / 10-00)

INDIANA PROFESSIONAL LICENSING AGENCY 302 W. WASHINGTON STREET, ROOM E034 INDIANAPOLIS, IN 46204 (317) 232-2980

INSTRUCTIONS: This application must be completed by the instructor and filed by the approved educator. Attach a resume.
Name of instructor Address (number and street, city, state, ZIP code)

Name of continuing education educator

QUALIFICATIONS Instructors must possess at least one (1) of the following minimum qualifications. Please indicate all that apply. 1) An instructor for a cosmetology school licensed under IC 25-8-5 Name of school: _____________________________________________________________________________________________________ Dates of experience: _________________________________________________________________________________________________ 2) Possession of a Bachelor's Degree from a college or university in a related field to that in which the person is to teach or a comparable degree from a school of a foreign country. (ATTACH TRANSCRIPT) List degree(s): _________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 3) Five (5) years of full-time experience in a profession, trade, or technical occupation relevant to cosmetology, manicuring, esthetics, or electrology. Indicate work experience below.
Name of present employer Employer address

Date employed: From: To: Name of past employer

Brief job description:

Employer address

Date employed: From: To: Name of past employer

Brief job description:

Employer address

Date employed: From: To: Name of past employer

Brief job description:

Employer address

Date employed: From: To: Name of past employer

Brief job description:

Employer address

Date employed: From: To:

Brief job description:

(over)

Outline in detail all teaching experience:

Outline in detail the qualifications which demonstrate your expertise in the cosmetology profession topics you will be teaching:

Have you attended an instructor class, seminar, or workshop in the last five years? If Yes, indicate the approximate date, type of course, and sponsor / provider:

Yes

No

Are you currently licensed as a cosmetology professional? Yes No If Yes, indicate the state you are licensed in, your license number, and length of time actively licensed:
State License number Length of time actively licensed

Have you ever had a cosmetology professional license or any other license to practice in another profession denied, restricted, suspended, or revoked? Yes No If Yes, explain on a separate sheet of paper. Is there any disciplinary action pending against you by a cosmetology board or licensing agency? If Yes, explain on a separate sheet of paper. Yes No

I, the undersigned, certify that the information given in this application is correct to the best of my knowledge.
Signature of instructor Date (month, day, year)

FOR OFFICE USE ONLY Approved Board comments: Tabled Denied

Board signature

Board signature