Free 43493.FH11 - Indiana

APPLICATION FOR COSMETOLOGY PROFESSIONAL LICENSE BY RECIPROCITY
State Form 43493 (R8 / 7-07) Approved by State Board of Accounts, 2007

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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 E-mail: [email protected]

* 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.

FOR OFFICE USE ONLY
Date approved by board (month, day, year) Receipt number Issuance fee License number issued Date fee paid (month, day, year) Date license issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE
Type of license (please check one)

Cosmetologist

Esthetician PART A - APPLICANT INFORMATION

Manicurist

Electrologist

Name of applicant (last, first, middle) Permanent mailing address (number and street, city, state, and ZIP code) Telephone number Date of birth (month, day, year)

Social Security number *

(

)

E-mail address

PART B - PRELIMINARY EDUCATION
Check the number of years completed 1 2 3 4 5 6 7 8 9 10 11 12 Year

PART C - RECORD OF LICENSURE
State of original licensure State of current licensure Title of original license Title of current license Number of original license Number of current license Date of issue (month, day, year) Date of issue (month, day, year)

PART D - RECORD OF TRAINING AND GRADES
Name of cosmetology school Address of cosmetology school (number and street, city, state, and ZIP code) Dates attended (month, day, year) T otal credit hours earned Final examination grade - written Course completed? License number

From:

T o:
Date of final examination (month, day, year)

Yes

No

Final examination grade - practical

Date of graduation (month, day, year)

PART E - SIGNATURE AFFIRMATION 1. Have you ever been convicted of an act for which you could be disciplined under IC 25-8-14 or a crime that has a direct bearing on your ability to practice competently? If yes, please attach supporting documentation relevant to the conviction.

Yes

No

I 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 (month, day, year)