Free 43716.FH11 - Indiana

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MONTHLY VERIFIED REPORT - COSMETOLOGY SCHOOL
State Form 43716 (R3 / 5-08) 820 IAC 4-1-10 (due 15th of each month)

PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204-2246 T elephone: (317) 234-3031 www.pla.IN.gov
School license number

Date of filing (month, day, year) Name of school Street address (number and street) City Telephone number State E-mail address

ZIP code

(
STATUS CODE*

)
STARTING DATE (month, day, year) COURSE CODE** TUITION OWED HOURS ACCRUED LAST DAY OF ATTENDANCE (month, day, year)

NAME OF STUDENT

* Status Code:

N = New G = Graduated DO = Dropout

** Course Codes:
AFFIDAVIT

ES = Esthetics M = Manicure

EL = Electrology S = Shampoo

C = Cosmetology I = Instructor

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 preparer Date (month, day, year)