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
}
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