Form 47401 - Affidavit - Certificate Of Use - Indiana Professional Licensingagency
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1AFFIDAVIT - CERTIFICATE OF USE
State Form 47401 (12-95)
I hereby certify and affirm that the tanning device(s), serial number(s)
_________________________________________________________________ , located at
_______________________________ , __________________________________ , Indiana
(name of facility)
(city)
______________________________ is / are exclusively for myself and my immediate family. I
(ID)
understand that should anyone, other than immediate family members, be allowed to use the
device(s), that the Indiana Professional Licensing Agency has authority to impose Civil Penalties
of up to one thousand ($1,000.00) dollars per occurrence. I further agree that this tanning device
or any other tanning device that possess or operate, will not be offered for use by anyone, other
than immediate family members, without first obtaining a License from the Indiana Professional
Licensing Agency.
Date (month, day, year)
Signature of owner
County
Signature of State Inspector, Indiana Professional Licensing Agency
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