Free 26770.FH11 - Indiana

APPLICATION FOR BARBER SHOP LICENSE
State Form 26770 (R6 / 6-08) 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 www.pla.IN.gov

INSTRUCTIONS:

1. 2. 3. 4. 5.

Please type or print. Include the license fee (call or visit our website for current fees). Barber shop must be ready to open at the time this application is filed. The barber shop license must be posted in the shop where it is visible to the public. Barber licenses must be posted in the work stations and be visible to the public.

* 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
Name of barber shop Shop address (number and street, city, state, and ZIP code) Name of shop owner (individual, partner, or officer) Home address (number and street, city, state, and ZIP code) Home telephone number Business telephone number E-mail address Social Security number * Federal identification number or Social Security number *

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If the barber shop is a partnership or corporation, list the partners of the partnership or the officers of the corporation. NAME TITLE ADDRESS (number and street, city, state, and ZIP code)

Pursuant to IC 25-7-1-1 (3) the barber shop will at all times be operated under the personal supervision and management of a registered barber.
Name of registered barber Shop hours Days open (check all that apply) Barber license number License date of expiration (month, day, year)

Sunday

Monday

Tuesday AFFIDAVIT

Wednesday

Thursday

Friday

Saturday

I (or we) will operate this establishment in compliance with the rules governing the sanitary requirements of barber shops as required by the State Board of Barber Examiners, and ensure that all employees comply with all requirements. (If barber shop is owned by a corporation or partnership, this application must be signed by an officer of the corporation or a partner of the partnership.) Have you, or an officer or a partner, ever committed an act for which you could be disciplined under IC 25-7-1-16.1? If the answer is Yes, please describe the act on a separate sheet of paper and attach to this application. Yes No

I certify that I personally completed this application and 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 applicant / corporate officer / partner Date (month, day, year)