Free 51120.PDF - Indiana

SF 51120 (11-02)

APPLICATION FOR COSMETOLOGY PROFESSIONAL TEMPORARY PERMIT

INSTRUCTIONS:

INDIANA PROFESSIONAL LICENSING AGENCY 302 W. WASHINGTON ST. ROOM E034 INDIANAPOLIS, IN 46204 (317)-232-2980 http://www.in.gov/pla

1. Complete section A of the application. 2. Supervising licensee completes sections B and C of the application. 3. Incomplete applications will not be considered.

**WALK IN TEMPORARY PERMITS WILL NOT BE ISSUED AFTER 4:15 PM **TEMPORARY PERMITS WILL NOT BE ISSUED TO PRACTICE IN A SALON THAT IS PRACTICING ON A TEMPORARY PERMIT

SECTION A - APPLICANT INFORMATION
Check the type of permit you are applying for: Name: Address: * Your Social Security number is being requested by this agency in accordnce with IC 4-1-8-1. Disclosure is mandatory and your application will not be processed without it. Social Security numbers are made available to the Department of Revenue.

Cosmetologist

Manicurist

Esthetician

Electrologist

Instructor

Social Security number * :

SECTION B - SUPERVISOR INFORMATION
Name of supervising licensee: Name of salon: Salon address: License number: Salon license number:

SECTION C - CERTIFICATION
I hereby certify that the above named applicant will be working in the above named salon under my supervision. Signature of supervising licensee: Date (month, day, year)