Free 51331.FH8 - Indiana

APPLICATION FOR WAIVER OF COSMETOLOGY PROFESSIONAL CONTINUING EDUCATION
State Form 51331 (4-03)

STATE OF INDIANA STATE BOARD OF COSMETOLOGY EXAMINERS INDIANA PROFESSIONAL LICENSING AGENCY 302 West Washington Street, Room E034 Indianapolis, IN 46204 317-232-2980 www.in.gov/pla

Per IC 25-8-15-9, a waiver or modification of the continuing education requirements may be requested if one of the following conditions exist. Requesting waiver on the basis of (check one): An emergency existed during the period for which the continuing education was required. Has had an incapacitating illness verified by the applicant and a licensed physician. Is licensed in another state that requires at least sixteen (16) hours of continuing education, and the cosmetology professional submits written verification to the board of compliance with the requirements of the other state. Was prevented from completing the continuing education requirement because of active military duty during the period for which the continuing education was required. PLEASE PROVIDE EVIDENCE WHICH WILL SUPPORT YOUR REQUEST FOR A WAIVER
Name of applicant Address (number and street, city, state, ZIP code) C/S/Z Signature of applicant Date (month, day, year) License number

Reason for request:

FOR OFFICE USE ONLY Approved
Comments:

Tabled

Denied

Signature

Date (month, day, year)