Free 45245.FH11 - Indiana

Reset Form

APPLICATION FOR EXAMINATION FOR BEAUTY CULTURE INSTRUCTOR LICENSE
State Form 45245 (R5 / 5-08) Approved by State Board of Accounts, 2008

INSTRUCTIONS: Please type or print legibly.

STATE BOARD OF COSMETOLOGY EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204-2246 Telephone: (317) 234-3031 E-mail: [email protected]

* Your Social Security number is being requested by this state agency in accordance with
I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. 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 TAPE A PHOTOGRAPH HERE THAT IS AT LEAST 2 X 3 IN SIZE.

DO NOT WRITE ABOVE THIS LINE APPLICANT INFORMATION
Name (first, middle initial, last)

Social Security number *

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

Date of birth (month,day, year)

Telephone number

E-mail address

(
Cosmetology license number

)
Date of expiration (month,day, year)

Manicurist license number

Date of expiration (month,day, year)

Electrologist license number

Date of expiration (month,day, year)

Esthetician license number

Date of expiration (month,day, year)

PRELIMINARY EDUCATION
Check the appropriate box for the number of years completed Received GED? Date (month, day, year)

1

2

3

4

5

6

7

8

9 PRACTICE

10

11

12

Yes

No

I have actively practiced cosmetology, esthetics, manicuring, or electrology in a salon from at
Name of salon Salon license number

Month, day, year

to

Month, day, year

; ; .

; ;

Address of salon Name of owner / manager of salon

INSTRUCTOR TRAINING

I have completed at

Months

of instructor training in a cosmetology school from
Name of school

Month, day, year

to

Month, day, year

; .

Page 1 of 2

STATEMENT PART E - STATEMENT / NOTARY CERTIFICATE
Have you ever committed an act for which you could be disciplined under IC 25-8-14?

Yes

No

If the answer is Yes, please describe the act on a separate sheet and attach to this application.
Have you ever been convicted, pled guilty or nolo contendere to any misdemeanor or felony in any state?

Yes

No

If the answer is Yes, please describe the act on a separate sheet and attach to this application.

I certify that I personally completed this application and that the answers appearing hereon 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)

TRANSCRIPT OF INSTRUCTOR TRAINING (to be completed by the Cosmetology School)
Date of enrollment (month, day, year) Date of graduation (month, day, year)

Practical Examination Grade

Total hours obtained

I do hereby certify and declare the transcript of training to be a correct and accurate record of the student enrolled at the school of cosmetology named below, and meets the requirements of the State Board of Cosmetology Examiners.
Printed name of student Signature of school official Date (month, day, year)

Name of cosmetology school

License number

Printed name of school official

COSMETOLOGY SCHOOL NOTARY CERTIFICATE

STATE OF ___________________________________ COUNTY OF _________________________________

}

SS:

Subscribed and sworn to before me, this _________ day of _____________________________________, 20_________.
Signature of Notary Public County of residence

Typed or printed name of Notary Public

Date commission expires (month, day, year)

Page 2 of 2