Free 45303.FH11 - Indiana

APPLICATION FOR EXAMINATION FOR BARBER INSTRUCTOR REGISTRATION
State Form 45303 (R5 / 3-08) Approved by State Board of Accounts, 2008

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

INSTRUCTIONS:

1. Please type or print legibly. 2. Include a photograph of yourself. 3. Include your examination fee (call or visit our website for current fees).

* 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.

FOR OFFICE USE ONLY
Application fee Receipt number Date fee paid (month, day, year) License number issued Date license issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE APPLICANT INFORMATION
Name of applicant Address (number and street, city, state, and ZIP code) Telephone number E-mail address Barber license number Social Security number *

(

)
EDUCATIONAL PREREQUISITES
Date of graduation or GED certificate (month, day, year):

Please check one

High school graduate
Have you completed the instructor education?

High school equivalency certificate (GED) INSTRUCTOR TRAINING
Date of enrollment (month, day, year) Date of graduation (month, day, year)

Yes
Name of school

No

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

DISCLOSURE OF CONVICTION RECORD
Have you ever been convicted of a crime?

Yes

No

If you have been convicted of a crime, please include a written explanation and copies of court documents. VERIFICATION AND SIGNATURE

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 completed this application and that the answers appearing herein are true and correct to the best of my knowledge and belief.
Signature of applicant Date (month, day, year)

CERTIFICATE OF TRAINING - THIS SECTION TO BE COMPLETED BY THE BARBER SCHOOL ON BEHALF OF THE EXAMINATION APPLICANT I hereby certify that ________________________________________________ has completed nine hundred (900) hours of instructor training and has
(name of applicant) (name of school)

graduated from the ________________________________________________ School of Barbering.
Signature of school director / instructor Printed name of school director / instructor Date (month, day, year)

NOTARY CERTIFICATE STATE OF _______________________________ COUNTY OF _____________________________ I ________________________________________________, having been duly sworn on oath, say that I am the above named school director / instructor, that I have personally prepared the foregoing certificate of training, and that the same is true to the best of my knowledge and belief.
Signature of school director / instructor Signature of Notary Public Printed name of school director / instructor Printed name of Notary Public Date subscribed and sworn to Notary Public (month, day, year) Date commission expires (month, day, year) (name of school director / instructor)