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State Form 45245 - Application For Examination For Cosmetology Esthetics, Or Electrology Instructor License - 2001 Page 2

PART E - STATEMENT / NOTARY CERTIFICATE

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

If the answer is Yes, please describe the act on a separate

sheet and attach to this application.

Yes

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.

Signature of applicant

STATE OF

}

SS:

COUNTY OF

Subscribed and sworn to before me, this __________ day of ______________________________, 20_________.

Signature of Notary Public

County of residence

Typed or printed name of Notary Public

Date commission expires

PART F - AFFIDAVIT OF PRACTICE

This part to be completed by an individual having knowledge of applicant's active practice of cosmetology, esthetics, or

electrology in a salon.

Name of applicant

License number

Name of salon

Address of salon

Salon license number

Date of expiration (month, day, year)

Name of owner / manager of salon

Dates of experience (month, day, year)

From:

To:

Please verify and describe the applicant's active practice of cosmetology, esthetics, or electrology

I swear and affirm that the above statements are true and correct to the best of my knowledge.

Signature of owner / manager

Printed name of owner / manager