Free 47871.FH11 - Indiana

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PROOF OF LICENSING
State Form 47871 (R6 / 4-09) Approved by State Board of Accounts, 2005

INDIANA DEPARTMENT OF EDUCATION OFFICE OF EDUCATOR LICENSING AND DEVELOPMENT 151 West Ohio Street Indianapolis, IN 46204 Toll Free: 1-866-542-3672 Fax: (317) 232-9023 www.doe.in.gov/educatorlicensing

INSTRUCTIONS:

1. To be completed only if your valid license has been lost or destroyed. 2. Attach to a renewal or duplicate application.

To the Office of Educator Licensing and Development / Public and Agency Support Services:

The State of Indiana issued to _______________________________________________________________________________________________ on
Give name exactly as it appears on license

________________________________, __________, a _____________________________________________________________________________ Serial Number _____________________________ of Grade ____________________, on the Basis of ________________________________________ with the Expiration Date of _______________________________________________. The license has been lost or destroyed. To the best of my knowledge, it was lost or destroyed in the following manner: __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________

I hereby swear (or affirm) that the above statements are true to the best of my knowledge and belief. I further agree that should the original license be found, it will be returned for cancellation.
Signature of applicant Address (number and street, city, state, and ZIP code) E-mail address

Subscribed and sworn to before me this ___________________________ day of _________________________, _______________.
Signature of Notary Public Typed or printed name of Notary Public Date commission expires (month, day, year) County of residence

Must include Notary seal