Free 45244.pdf - Indiana

APPLICATION FOR EXAMINATION FOR ESTHETICIAN OR ELECTROLOGIST
State Form 45244 (R5 / 7-01) Approved by State Board of Accounts 2001

INDIANA PROFESSIONAL LICENSING AGENCY 302 West Washington Street, Room E034 Indianapolis, Indiana 46204-2700 (317) 232-2980

INSTRUCTIONS: Submit examination fee with application. CANDIDATES SHALL BE ADVISED OF LICENSE FEE WITH NOTIFICATION OF PASSING THE EXAMINATION. ATTACH A PHOTOGRAPH. Examination Fee: $25.00

(Please check one)

ESTHETICIAN ELECTROLOGIST

Social Security number *

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

PART A: IDENTIFYING INFORMATION (to be completed by applicant)
Name of applicant (first, middle initial, last) Age

Maiden name

Date of birth (month, day, year)

Telephone number ( )

Permanent mailing address (number and street, city, state, ZIP code)

County

Cosmetologist license number (Electrologist applicants may list their Esthetician license number)

Expiration date

PART B: PRELIMINARY EDUCATION
Circle the number of years completed: Received GED? Date received Yes No

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Name of grade school:

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

Dates attended: (months, years)

Name of high school:

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

Dates attended: (months, years)

Graduated:

PART C: 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. NOTARY CERTIFICATE (SWORN OATH) 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. STATE OF COUNTY OF Subscribed and sworn to before me on this ______________________________ day of __________________________________ , __________ .

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Signature of applicant

Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence

(Continued on the reverse side)

THIS SIDE TO BE COMPLETED BY COSMETOLOGY SCHOOL PART D: TRANSCRIPT OF TRAINING (ESTHETICIAN) HOURS TRAINING Chemistry of skin care Physiology and dermatology Bacteriology, sterilization and sanitation Introduction / Operation to skin care machinery Skin care Makeup Eyebrow and lashes Hair removal Signature of school official TOTAL HOURS HOURS TRAINING Safety precautions Professional and personality development Management Salemanship and marketing State law and rules Testing evaluation Discretionary hours

PART E: PROGRESS REPORT (ACTUAL PRACTICE) ESTHETICIAN HOURS ACTUAL PRACTICE Chemistry of skin care Physiology and dermatology Bacteriology, sterilization and sanitation Introduction / Operation to skin care machinery Introduction to skin care Skin care Makeup TOTAL HOURS
Signature of school official

HOURS Eyebrow and lashes Hair removal Safety precautions

ACTUAL PRACTICE

Testing evaluation Salemanship and marketing Discretionary hours

HOURS Applied anatomy Applied electrolysis TOTAL HOURS

TRAINING

PART F: TRANSCRIPT OF TRAINING (ELECTROLOGISTS) HOURS Patron protection Sanitation

TRAINING

Signature of school official

HOURS Applied electrolysis TOTAL HOURS

ACTUAL PRACTICE
Signature of school official

PART G: PROGRESS REPORT (ACTUAL PRACTICE) ELECTROLOGY HOURS ACTUAL PRACTICE Sanitation

PART H: STUDENT INFORMATION
Name of student Dates attended (month, day, year) From: Final examination grades: Practical: Name of cosmetology school Written: School license number To: Final examination date (month, day, year) Enrolled in training for: Course completed? Yes Graduation date (month, day, year) No

Total credit hours earned

Address of cosmetology school (number and street, city, state, ZIP code)

PART I: SCHOOL CERTIFICATION I do hereby certify and declare this transcript of training and progress report 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.

STATE OF COUNTY OF

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Subscribed and sworn to before me this ___________________ day of _________________________________ , ______________.

Signature of school official

Signature of Notary Public

Printed or typed name of school official

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence

ATTACH A PHOTOGRAPH THAT IS AT LEAST 2" X 3" IN SIZE TO THE AREA BELOW.