Free 46221.PDF - Indiana

REQUEST FOR WAIVER OF SIX MONTH LICENSURE REQUIREMENT
State Form 46221 (R / 7-99)

INDIANA PROFESSIONAL LICENSING AGENCY Indiana State Board of Cosmetology Examiners 302 West Washington Street, Room E034 Indianapolis, Indiana 46204 Telephone: 317-232-2980

INSTRUCTIONS: Please complete this form in it's entirety and return to the Indiana Professional Licensing Agency. Requests For Waiver Of Six Month Licensure Requirement are reviewed monthly by the State Board of Cosmetology Examiners. Upon review, you will be notified in writing of the Board approval / denial.

REQUEST FOR WAIVER OF SIX MONTH LICENSURE REQUIREMENT (IC 25-8-7-3; IC 25-8-12.6-3, IC 25-8-7.1-3, IC 25-8-7.2-3)

On this ___________ day of ___________________________ , _______ , I, ___________________________________________________________ ,
Name

__________________________________________________________________________________________________________________________
Address

respectfully request the Board of Cosmetology Examiners to waive the requirement on holding a cosmetologist license, or esthetician license manicurist license electrologist license

for six (6) months prior to submitting my application for a cosmetology salon license, or esthetician shop license (A) State reason(s) for requesting waiver: manicurist salon electrology salon.

(B) Signature of two (2) persons who know me and are familiar with the fact(s) set forth above.
Date signed

(1)
Date signed

(2)
Signature of applicant License number

NOTARIZATION Before me, a notary public, personally appeared _____________________________________________________________ who subscribed and swore to the foregoing.
Signature of Notary

Printed or typed name of Notary (SEAL) County of residence Commission expiration date

State