Free 45241.pdf - Indiana

APPLICATION FOR ELECTROLOGY SALON
State Form 45241 (R2 / 9-01) Approved by State Board of Accounts 1993

LICENSE FEE: $40.00

Indiana Professional Licensing Agency 302 West Washington Street, Room E034 Indianapolis, Indiana 46204-2246 Telephone: (317) 232-2980

Social Security number or Federal ID number *

* Social Security number is requested by this agency in accordance with IC 4-1-8-1, and is mandatory that it be given. Social Security numbers are available to the Indiana Department of Revenue.

APPLICANT INFORMATION
Name of salon applicant

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

Name of salon (not more than 29 characters including spaces)

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

Telephone number of salon ( )

Telephone number of residence ( )

County code (see listing) Supervising electrologist license number

Name of supervising licensed electrologist [six (6) months active experience prior to application]

Nearest highway number (if salon is located on Rural Route)

Location of salon

Business
For direction from main highway, please indicate the N / S road and E / W road "hundred" numbers in appropriate spaces below: ____________ North ____________ Name of road (if applicable) ____________ South ____________ ____________ East ____________ Name of nearest town

Residential
____________ West ____________

Give specific directions to salon (exact location with respect to a residence or surrounding building):

Approximate opening date

Normal salon hours

Check days open

S
Is this salon connected in any way with residential living quarters?

M

T

W

TH Yes

F No

S

If yes, is the salon separated from the residence by a substantial floor to ceiling partition with a separate entry?

If yes, explain the nature of the separation:

SALON REQUIREMENTS 1. One (1) sink or bowl with hot and cold running water. 2. One (1) treatment table. 3. One (1) treatment stool. 4. One (1) lamp. 5. One (1) closed cabinet for storage of clean linens. 6. One (1) closed hamper for storage of soiled linens. 7. One (1) covered waste receptacle . 8. Twelve (12) pairs of disposable rubber gloves. 9. One (1) face mask. 10. One (1) steam autoclave sterilizer. 11. Twelve (12) sterile needles. 12. Six (6) pairs of tweezers. 13. One (1) epiletor. 14. Twelve (12) clean coverings for chair and table where electrology is performed. 15. Twelve (12) clean drapings for securing between electrologist and customer during an electrology session. 16. One (1) bottle for skin sanitizing agent. 17. One (1) bottle of residue detergent or one (1) bottle of solution having at least seventy percent (70%) alcohol. 18. One (1) covered container each for supplies such as cotton, lip rolls, etc. (Continued on the reverse side)

SALON REQUIREMENTS (continued) 19. Salon shall have sanitary requirements and all licenses posted and a sign visible at the main public entrance of the salon stating the name of the establishment and that the establishment is an electrology salon. 20. A change in salon ownership or location will require the filing of a new salon application. 21. Any person providing electrology services in the salon must possess a valid electrology license issued by the Board of Cosmetology Examiners. If the salon is owned by a corporation or partnership, list the name, title and address of the officers of the corporation or partners of the partnership. NAME TITLE ADDRESS

AFFIDAVIT I will operate establishment in compliance with the rules governing the sanitary requirements of electrology salons as required by the State Board of Cosmetology Examiners, and ensure that all employees comply with all requirements. (If electrology salon is owned by a corporation or partnership, this application must be signed by an officer of the corporation or a partner of the partnership.) The electrology salon will be under the personal supervision of expiring was submitted.
Have you ever committed an act for which you could be disciplined under IC 25-8-14? If yes, please describe the act on a separate sheet of paper and attach to this application.

, license number

,

, who has at least six (6) months active experience as a licensed electrologist under IC 25-8-10 before the application

Yes

No

STATE OF COUNTY OF

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SS:

I, , having been duly sworn on oath, say that I am the above-named, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of applicant / corporate officer / partner Signature of Notary Public

Printed or typed name of applicant / corporate officer / partner

Printed or typed name of Notary Public

Date subscribed and sworn to Notary Public

County of residence

Date commission expires