Free 51772.FH11 - Indiana

APPLICATION FOR BARBER PROFESSIONAL TEMPORARY PERMIT
State Form 51772 (R / 7-08)

Reset Form

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

INSTRUCTIONS:

1. Complete section A of this application. 2. Supervising licensee completes sections B and C of the application. 3. Incomplete applications will not be considered. Temporary permits will not be issued to practice in a shop that is practicing on a temporary permit.
* 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. Social Security numbers are available to the Indiana Department of Revenue.

APPLICATION INFORMATION
Type of permit for which you are applying (check one)

Barber
Name of applicant Address (number and street, city, state, and ZIP code)

Instructor
Social Security number *

SUPERVISOR INFORMATION
Name of supervising licensee Name of shop / school Address of shop / school (number and street, city, state, and ZIP code) License number License number of shop / school

CERTIFICATION I hereby certify that the above named applicant will be working in the above named shop/school under my supervision.
Signature of supervising licensee Date (month, day, year)