Free 44671.FH11 - Indiana

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APPLICATION FOR BARBER SCHOOL LICENSE
State Form 44671 (R2 / 5-08) Approved by State Board of Accounts, 2008

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

INSTRUCTIONS: The following documents shall accompany the application: 1. Detailed drawing of barbering school premises, including size of the building and number of barber chairs. 2. Financial statement, certified by a public accountant or certified public accountant including assets, liabilities and net worth of the person, partnership or corporation applicant. 3. Evidence of a performance bond of twenty-five thousand dollars ($25,000) guaranteeing the operation of such school of barbering for three (3) years and conditioned upon compliance with barbering laws and rules. 4. Copy of curriculum, tuition rates, and student contract. The curriculum shall be organized in written form showing the sequence in which various subjects are to be taught and the number of sessions or hours for each subject. 5. State Fire Marshall inspection report. 6. Copy of current corporate filings. 7. License fee. (Call or check our website for current fees.)

FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER ISSUED DATE LICENSE ISSUED (month, day, year) LICENSE OBTAINED BY

DO NOT WRITE ABOVE THIS LINE

I (we) hereby make application for a license to conduct a school of barbering in the state of Indiana under the provisions of the Indiana State Board of Barber Examiners, IC 25-7-1 and Title 876.
Name of school of barbering Telephone number

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

)

E-mail address

Social Security number and / or Federal Identification number *

* Social Security number and / or Federal ID number is requested by this agency in accordance with IC 4-1-8-1, and is mandatory that it be given. These numbers are available to the Indiana Department of Revenue.

BARBERING INSTRUCTORS

LICENSE NUMBER

INDIVIDUAL, PARTNERS OR CORPORATE OFFICERS NAME ADDRESS TITLE

If a corporation, date and state of incorporation:
Date of incorporation (month, day, year) State of incorporation Approximate date of opening (month, day, year)

AFFIDAVIT Applicant hereby certifies: that applicant will comply with the licensing requirements under IC 25-7 and IAC 816; and that applicant, if an individual, partners of a partnership, or officers of a corporation has not been convicted of an act which would constitute a ground for disciplinary sanction under IC 25-7-116.1 or a felony that has direct bearing on the applicant's ability to practice competently. In addition, I certify that the information appearing hereon is 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 individual / partner / corporate officer Date (month, day, year)

Printed or typed name of individual / partner / corporate officer