Free 51773.FH11 - Indiana

APPLICATION FOR BARBER INSTRUCTOR LICENSE BY RECIPROCITY
State Form 51773 (R2 / 5-08) Approved by State Board of Accounts, 2008

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STATE BOARD OF BARBER EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3031 E-mail: [email protected] www.pla.IN.gov

INSTRUCTIONS:

Include the license fee (call or visit our website for current fees), the license certifications from the state(s) in which you are licensed, and a photograph of yourself with your completed application.

* 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.

FOR OFFICE USE ONLY
Application fee License number issued Date fee paid (month, day, year) Date license issued (month, day, year) Receipt number License obtained by

DO NOT WRITE ABOVE THIS LINE

APPLICANT INFORMATION
Name of applicant (last, first, middle) Social Security number *

Address (number and street, city, state and ZIP code)

T elephone number

E-mail address

Barber license number

(

)
If yes, please include a written explanation and copies of court documents.

Have you ever been convicted of a crime?

Yes

No

Have you graduated high school or obtained the equivalent of a high school diploma?

Yes

No

Indicate license information for all barber and barber instructor licenses you hold or have held in any other state. STATE TYPE OF LICENSE LICENSE NUMBER EXPIRATION DATE (month, day, year)

VERIFICATION AND SIGNATURE I do hereby certify and declare that I will abide by and obey all provisions of the law and rules adopted by the board. I hereby certify that I completed this application and that the answers appearing herein 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)