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APPLICATION FOR TANNING FACILITY LICENSE
State Form 47393 (R2 / 7-08) Approved by State Board of Accounts, 2008

PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204-2700 Telephone: (317) 234-3031 www.IN.gov/pla

INSTRUCTIONS: This application must be completed in its entirety. Call or visit our website for current fees.

* 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

DO NOT WRITE ABOVE THIS LINE TYPE OF APPLICATION NEW FACILITY (Fee: Call or visit our website for current fees) GENERAL INFORMATION
Name of tanning facility Address (number and street, city, state, and ZIP code) E-mail address Number of facilities owned Telephone number Number of tanning devices

TRANSFER (No fee)

(
INFORMATION ABOUT THE OWNER
Name of owner Address (number and street, city, state, and ZIP code)

)

Telephone number

(

)

Social Security number *

Tanning Equipment Registration: The applicant shall only use tanning equipment manufactured in accordance with specifications set forth in 21 Code of Federal Regulations, Part 1040, Section 1040.20, "Sunlamp Products and Ultraviolet Lamps Intended For Use in Sunlamp Products." If a tanning device is deleted and / or added, notify the Agency immediately. ADDITIONAL DEVICES MAY BE SPECIFIED ON BACK MANUFACTURER MODEL SERIAL YR. / MO. MFGD. UNIT TYPE BED BOOTH BULB TYPES

Pursuant law, the applicant certifies he/she has read and understands the requirements of the law, that all information contained herein is true and correct to the best of his/her knowledge. 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 owner Printed name of owner Date of application (month, day, year)