Free 46041.FH11 - Indiana

Reset a Form

APPLICATION FOR COSMETOLOGY INSTRUCTOR BY RECIPROCITY
State Form 46041 (R2 / 6-07)

STATE BOARD OF COSMETOLOGY EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 T elephone: (317) 234-3031 E-mail: [email protected]

INSTRUCTIONS: 1. Please type or print legibly. 2. Part I is to be completed by the applicant. 3. Part II is to be completed by an individual having knowledge of the applicants active practice in a cosmetology salon.

* Your Social Security number is being requested by this state agency in accordance with
I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. PART I IDENTIFYING INFORMATION
Title of license for which you are applying

Name of applicant (first, middle initial, last )

Social Security number *

Maiden name (if applicable)

Permanent mailing address (number and street, city, state, and ZIP code)

County

Date of birth (month, day, year)

Telepone number

E-mail address

(
Check the appropriate box for the number of years completed 1 Name of grade school 2 3 4 5 6 7 8

)
Received GED? 9 10 11 12 Yes No Date (month, day, year)

PRELIMINARY EDUCATION

Address of grade school (number and street, city, state, and ZIP code)

Dates attended (from- to; month, year)

Date graduated (month, day, year)

Name of high school

Address of high school (number and street, city, state, and ZIP code)

Dates attended (from-to; month, year)

Date graduated (month, day, year)

RECORD OF LICENSURE

Please complete the information below concerning your license to practice the profession named above.
State of original license Title of original license Number of original license Date of issue (month, year)

State of current license

Title of current license

Number of current license

Date of issue (month, year)

RECORD OF TRAINING AND GRADES
Name of school of cosmetology Dates attended (from- to; month, year)

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

T otal credit hours earned

Did you complete the course?

Yes
Final practical grade Final written grade Date of final examination (month, day, year)

No

Date of graduation (month, day, year)

CRIMINAL HISTORY

Have you ever been convicted of a criminal act?

Yes

No

If Yes, please provide official documentation explaining the conviction and sentence.
Page 1 of 2

STATEMENT

I do hereby certify and declare that I will abide by and obey all provisions of the law and rules adopted by the board. I hereby certify that I personally completed this application and that the answers appearing hereon are true and correct to the best of my knowledge and belief. I understand that providing fraudulent information may be grounds for refusal to issue the license for which I am applying, or for disciplinary action against the license which may be issued.
Signature of applicant Date signed (month, day, year)

PART II AFFIDAVIT OF COSMETOLOGY PRACTICE
Name of applicant License number

Name of cosmetology salon

Address of cosmetology salon (number and street, city, state, and ZIP code)

Salon license number

Expiration date (month, day, year)

Name of owner / manager of salon

Date of experience (month, day, year)

From:
Please verify and describe the applicant's active practice of cosmetology.

To:

Signature of owner / manager of salon

Printed name of owner / manager of salon

Date (month, day, year)

Page 2 of 2