State Form 45245 - Application For Examination For Cosmetology Esthetics, Or Electrology Instructor License - 2001

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APPLICATION FOR EXAMINATION FOR COSMETOLOGY
Indiana Professional Licensing Agency
302 W. Washington St., Rm. E034
ESTHETICS, OR ELECTROLOGY INSTRUCTOR LICENSE
Indianapolis, IN 46204-2246
State Form 45245 (R3 / 9-01)
FEE: $15.00
Approved by State Board of Accounts, 2001
* Your Social Security number is being re-
quested by this agency in accordance with IC
4-1-8-1. Disclosure is MANDATORY. Social
Security numbers are made available to the
Indiana Department of Revenue.
INSTRUCTIONS:
Submit Instructor examination fee with application.
Attach a photograph.
Candidates shall be advised of license fee with notification of passing the examination.
Social Security number *
Check one:
Cosmetology
Esthetics
Electrology
PART A - IDENTIFYING INFORMATION (to be completed by applicant)
First name
M.I.
Last name
Maiden name (if applicable)
Age
Date of birth (month, day, year)
Telephone number
(
)
Permanent mailing address (number and street)
City
State
ZIP code
County
Cosmetology License Number:
Date of expiration (month, day, year)
Electrologist License Number:
Date of expiration (month, day, year)
Esthetician License Number:
Date of expiration (month, day, year)
PART B - PRELIMINARY EDUCATION
Circle the number of years completed
Received GED?
If Yes, date received (month, year)
1
2
3
4
5
6
7
8
9
10
11
12
Yes
No
Name of grade school
Address of grade school
Dates attended (month, year)
Date graduated (month, year)
From:
To:
Name of high school
Address of high school
Dates attended (month, year)
Date graduated (month, year)
From:
To:
PART C - PRACTICE
I have actively practiced cosmetology, esthetics, or electrology in a salon from__________________ to __________________
Month, day, year
Month, day, year
at___________________________________________________; __________________________________________________;
Name of salon
Address of salon
________________________________________; ______________________________________________________________.
Salon license number
Name of owner / manager of salon
PART D - INSTRUCTOR TRAINING
I have completed _______________ of instructor training in a cosmetology school from ______________________________ to
Months
Month, day, year
______________________________; at _____________________________________________________________________;
Month, day, year
Name of school
________________________________________________________________; _____________________________________.
Address of school
School license number
Name of school official

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