Free 15969.FH11 - Indiana

APPLICATION FOR EXAMINATION FOR COSMETOLOGIST, MANICURIST, ESTHETICIAN, OR ELECTROLOGY LICENSE
State Form 15969 (R8 / 5-08) Approved by State Board of Accounts, 2008

Reset Form

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. Social Security numbers are available to the Indiana Department of Revenue.

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

Manicurist

Esthetician

Electrologist

PART A - APPLICANT INFORMATION
Name of applicant (last, first, middle) Permanent mailing address (number and street, city, state, and ZIP code) Telephone number (daytime) Date of birth (month, day, year) E-mail address Social Security number *

(

)

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 - SIGNATURE AFFIRMATION 1. 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 and attach the application. 2. Have you ever been convicted of a crime? If yes, please provide official documentation explaining the conviction and sentence. Yes Yes No 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)

PART D - COSMETOLOGY SCHOOL CERTIFICATION OF EDUCATION (to be completed by cosmetology school only)
Name of student Name of cosmetology school Did this student transfer from another school? If yes, name of school Final practical examination grade Type of education (check one)

Cosmetologist

Manicurist
License number

Esthetician

Electrologist

Yes
Date of enrollment (month, day, year)

No
Date of graduation (month, day, year) Total theory and demonstration hours T otal actual practice hours

Affix school seal here.

Page 1 of 2

AFFIDAVIT I do hereby certify and declare the certification of education to be a correct and accurate record for the student indicated above and that the student meets the graduation requirements pursuant to the State Board of Cosmetology Examiners statutes and rules. I understand that providing fraudulent information may be grounds for refusal to issue the license for which is being applied and disciplinary action against the cosmetology school license. STATE OF _______________________________ COUNTY OF _____________________________ SS:

Subscribed and sworn to before me this ____________ day of __________________________________________, ____________.
Signature of school director / instructor Printed name of school director / instructor Signature of Notary Public Printed name of Notary Public County of residence Date commission expires (month, day, year) Date subscribed and sworn to Notary Public (month, day, year)

Attach photograph here.

Page 2 of 2