Free 45993.pdf - Indiana


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AFFIDAVIT OF WORK EXPERIENCE
State Form 45993 (5-93)

INDIANA PROFESSIONAL LICENSING AGENCY 302 West Washington Street, Room E034 Indianapolis, Indiana 46204-2700 Telephone number: (317) 232-2980

TO BE COMPLETED BY AN INDIVIDUAL HAVING KNOWLEDGE OF APPLICANT'S EMPLOYMENT.

Name of applicant

License number

Name of salon / shop

Name of owner or manager of salon / shop

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

Experience dates (month, day, year) From: Please verify and describe the work experience of the applicant To:

NOTARY CERTIFICATE (SWORN OATH)

STATE OF COUNTY OF

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SS:

I swear and affirm that the above statements are true and correct to the best of my knowledge.
Signature of owner or manager of salon / shop Signature of Notary Public

Printed or typed name of owner or manager of salon / shop

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence