Free 47836.FH11 - Indiana

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MONTHLY VERIFIED REPORT - BARBER SCHOOL
State Form 47836 (R / 7-08)

STATE BOARD OF BARBER EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-3031 www.pla.IN.gov
School license number

Date of filing (month, day, year)

Name of school

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

Telephone number

E-mail address

(

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HOURS ACCRUED LAST DAY OF AS OF LAST ATTENDANCE REPORT

STARTING STATUS DATE CODE * (month, day, year)

NAME OF STUDENT

TUITION OWED

* Status Code:

N = New DO = Dropout

G = Graduated PG = Pending Graduation CERTIFICATION

I certify that I personally completed this report 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 disciplinary action against the license of this school.
Signature of school manager

Printed or typed name of school manager

AFFIX SCHOOL SEAL HERE

Date (month, day, year)