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Form 45244 - Application For Examination For Esthetician Or Electrologist - Indiana Professional Licensing Agency - 2001

APPLICATION FOR EXAMINATION

INDIANA PROFESSIONAL LICENSING AGENCY

FOR ESTHETICIAN OR ELECTROLOGIST

302 West Washington Street, Room E034

State Form 45244 (R5 / 7-01)

Indianapolis, Indiana 46204-2700

Approved by State Board of Accounts 2001

(317) 232-2980

INSTRUCTIONS: Submit examination fee with application. CANDIDATES SHALL BE ADVISED OF

LICENSE FEE WITH NOTIFICATION OF PASSING THE EXAMINATION.

Examination Fee: $25.00

ATTACH A PHOTOGRAPH.

* Social Security number is requested by this agency in accordance with IC

Social Security number *

(Please check one)

ESTHETICIAN

4-1-8-1, and is mandatory that it be given. Social Security numbers are

ELECTROLOGIST

available to the Indiana Department of Revenue.

PART A: IDENTIFYING INFORMATION (to be completed by applicant)

Age

Name of applicant (first, middle initial, last)

Maiden name

Date of birth (month, day, year)

Telephone number

(

)

Permanent mailing address (number and street, city, state, ZIP code)

County

Cosmetologist license number (Electrologist applicants may list

Expiration date

their Esthetician license number)

PART B: PRELIMINARY EDUCATION

Date received

Circle the number of years completed:

Received GED?

Yes

Name of grade school:

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

Graduated:

Dates attended: (months, years)

Name of high school:

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

Dates attended: (months, years)

Graduated:

PART C: STATEMENT / NOTARY CERTIFICATE

Have you ever committed an act for which you could be disciplined under IC 25-8-14?

Yes

If the answer is Yes, please describe the act on a separate sheet and attach to this application.

NOTARY CERTIFICATE (SWORN OATH)

I certify that I personally completed this application and that the answers appearing hereon are true and correct to the best of my knowledge and belief. 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.

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STATE OF

SS:

COUNTY OF

Subscribed and sworn to before me on this ______________________________ day of __________________________________ , __________ .

Signature of applicant

Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public

Date subscribed and sworn to Notary Public

Date commission expires