State Form 26770 - Application For Barber Shop License printable pdf download

Indiana Professional Licensing Agency

APPLICATION FOR BARBER SHOP LICENSE

302 W. Washington St., Rm. E034

Indianapolis, IN 46204-2700

State Form 26770 (R5 / 7-01)

Telephone: (317) 232-2980

Approved by State Board of Accounts, 2001

FOUR (4) YEAR LICENSE FEE: $40.00

PLEASE TYPE OR PRINT

Name of shop

Shop address (number and street, city, state, ZIP code)

Name of shop owner (individual, partner, or officer)

Social Security number *

Home address (number and street, city, state, ZIP code)

Business telephone number

Residence telephone number

Social Security number or Federal ID number *

* This agency is requesting disclosure of your Social Security number under IC 4-1-8-1. Disclosure is

mandatory. This record cannot be processed without it.

If the barber shop is a partnership or corporation, list the partners of the partnership or the officers of the corporation.

TITLE

ADDRESS

NAME

Pursuant to IC 25-7-1-1 (3) the barber shop will at all times be operated under the personal supervision and management of a registered barber.

Name of registered barber

Certificate of Registration expiring

Barber Certificate of Registration number

Approximate opening date

Shop hours

Check days open

AFFIDAVIT

I (or we) will operate this establishment in compliance with the rules governing the sanitary requirements of barber shops as required by the

State Board of Barber Examiners, and ensure that all employees comply with all requirements. (If barber shop is owned by a corporation or

partnership, this application must be signed by an officer of the corporation or a partner of the partnership.)

The barber shop will be under the personal supervision and management of a licensed barber _______________________________________ ,

(name of barber)

Certificate of Registration number ________________________ , expiring ____________________ .

Have you, or an officer or a partner, ever committed an act for which you could be disciplined under IC 25-7-1-16.1?

Yes

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

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

Signature of applicant / corporate officer / partner

NOTARY CERTIFICATE (SWORN OATH)

STATE OF

}

SS:

COUNTY OF

, having been duly sworn on oath, say that I am the

above-named applicant, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.

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

County of residence

State Form 26770 - Application For Barber Shop License

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