Free 45654.FH11 - Indiana

APPLICATION FOR COSMETOLOGY SCHOOL LICENSE
State Form 45654 (R3 / 6-08) Approved by State Board of Accounts, 2008

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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 www.IN.gov/pla

INSTRUCTIONS:

1. Type or print. 2. Enclose check or money order for license fee, payable to the Professional Licensing Agency (call or check our website for current fees). 3. Pursuant to 820 IAC 2-1-4, this application shall be accompanied by the following documents: a. The contract which is to be used between the cosmetology school and its students which must include the school's refund policy; b. A copy of the cosmetology school's deed for the property where the cosmetology school is located or a lease for at least one (1) year showing that the premises are to be used as a cosmetology school; c. A budget for the first year of operation of the cosmetology school; d. A financial statement on a form provided by the board (see pages 2 and 3 of this form); e. A floor plan of the cosmetology school of which shall show, in detail, the following; 1) the placement of students 2) classroom entrances and exits 3) space for waiting customers (indicating number of chairs) 4) separate student and public cloakroom spaces 5) separate restrooms for men and women; and f. A list of licensed instructors who will be teaching in the cosmetology school (including license numbers).

* 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
Application fee License number issued Date fee paid (month, day, year) Date license issued (month, day, year) Receipt number License obtained by

DO NOT WRITE ABOVE THIS LINE
I. Name of cosmetology school II. Address of cosmetology school (number and street, city, state,and ZIP code) III. Cosmetology school telephone number IV. Social Security and / or Federal Identification number * E-mail address

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V. Name(s) and address(es) of cosmetology school owner(s): Name of owner Address (number and street, city, state, and ZIP code) Name of owner Address (number and street, city, state, and ZIP code) Name of owner Address (number and street, city, state, and ZIP code) VI. Name(s) and address(es) of corporate officers of corporation (if applicable) Name of corporate officer Address (number and street, city, state, and ZIP code) Name of corporate officer Address (number and street, city, state, and ZIP code) Name of corporate officer Address (number and street, city, state, and ZIP code)

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VII. Name(s) and address(es) of partners of partnership (if applicable) Name of partner Address (number and street, city, state, and ZIP code) Name of partner Address (number and street, city, state, and ZIP code) VIII. The school will be operated under the personal supervision of the licensed cosmetology instructor listed below: Name of instructor Address (number and street, city, state, and ZIP code) IX. Affirmation License number

A. I, or owner(s), or officer(s), or partner(s), have have not committed an act that would be grounds for refusal to issue license under IC 25-8-14-2, (if an act or acts have been committed, please attach supporting documentation concerning same); B. I am the owner / officer / partner of the aforementioned cosmetology school; and C. I have personally prepared the foregoing application and that the same is true to the best of my knowledge and belief. D. 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 Printed name of applicant Date signed (month, day, year)

FINANCIAL STATEMENT IN SUPPORT OF APPLICATION FOR COSMETOLOGY SCHOOL LICENSE [Pursuant to 820 IAC 2-1-4(a)(5)] THIS FINANCIAL STATEMENT MUST BE COMPLETED BY A CERTIFIED PUBLIC ACCOUNTANT.
Name of school owner / officer / partner Cosmetology school address (number and street, city, state, and ZIP code) Name of cosmetology school

ASSETS, LIABILITIES AND EQUITIES OF COSMETOLOGY SCHOOL (See Financial Statement Explanation with corresponding number for each line number below) A. ASSETS / LIABILITIES ASSETS 1. Cash in banks 2. Negotiable investments 3. Prepaid investments 4. Merchandise 5a. Accounts receivable (students) 5b. Accounts receivable (other) 6. Total current assets 7. Equipment (cost) Less depreciation 8. Land 9. Building 10. Other assets (ALL) 11. TOTAL ASSETS LIABILITIES 12. Accounts payable 13. Notes payable (one year) 14. Other payables 15. Unearned tuition 16. Total current liabilities 17. Long term debts 18. Other liabilities 19. Total liabilities 20. Owner(s) capital 21. Capital stock 22. Paid-in surplus 23. Retained earnings 24. TOTAL LIABILITIES AND EQUITY $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

B. In the event any one of the two following exist from "A", a personal financial statement and guarantee could help the school meet the financial responsibility tests if its own financial statement does not meet them: 1. Line 16 is greater than line 6. 2. Line 19 is greater than Line 11. Page 2 of 3

C. Detailed description of method used in earning tuition income:

D. I verify that the foregoing is true and correct to the best of my knowledge, information and belief.
Signature of preparer Printed name of preparer Date signed (month, day, year)

FINANCIAL STATEMENT EXPLANATION ASSETS: 1. Cash in banks: firm corporation/partnership must show cash in all accounts (including savings accounts). 2. 3. 4. Negotiable investments: include any investments that could be converted to cash immediately or within one (1) year. If investments are stocks and/or bonds, attach schedule showing name of stocks and/or bonds and market value. Prepaid expenses: include any monies paid for future expenses. Examples: insurance premiums, deposits, and service contracts paid for the following year. Merchandise: include cost of merchandise on hand to be used for demonstration and instruction that could be sold.

5a. Accounts receivable: list all monies owed to the school by enrolled students by contingent contracts. 5b. Total of all other accounts receivable other than student contracts. 6. 7. 8. 9. Total current assets: total of amounts shown under items (1) through (6). Equipment: include fixed assets required to operate the school (examples include desks, tables, chairs, lighting, equipment, etc.) less depreciation. Land: include land owned by the school. Building: include building owned by the school less depreciation.

10. Other assets: include other assets owned by the school less depreciation. 11. Total assets: total of amounts shown under items (6) through (10). LIABILITIES: 12. Accounts payable: list all monies the school owes to creditors payable within one (1) year. Examples: utility bills, rent, merchandise purchased on open accounts, service contracts, payroll, and sales taxes. 13. Notes payable: include all note payments due and payable within one (1) year. 14. Other payables: itemize any other amounts owned and payable within one (1) year. 15. Unearned tuition: represents tuition paid in advance by students and/or amounts shown as accounts receivable tuition. Complete section describing the method used to record earned tuition income. 16. Total current liabilities: total of amounts shown under items (12) through (15). 17. Long term debt: include all obligations owed by the school payable in more than one (1) year. Examples: long term loans, equipment leases, auto loans, owner(s) or officer(s) or partner(s) loans. 18. Other liabilities: include all other amounts owed by the school. 19. Total liabilities: total of amounts shown under terms (16) through (18).

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