Form 47871 - Proof Of Licensing - Indiana Professional Standards Board
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1SOCIAL SECURITY NUMBER
Indiana Professional Standards Board
PROOF OF LICENSING
251 E. Ohio St., Suite 201
Your Social Security number is being requested
Indianapolis, IN 46204-2133
by this state agency pursuant to IC 4-1-8-1. Dis-
State Form 47871 (7-96)
Telephone: (317) 232-9010
closure is voluntary and you will not be penalized
Fax: (317) 232-9023
Approved by State Board of Accounts, 1996
for not disclosing it.
Office Hours: 8:00 a.m. to 4:30 p.m.
Social Security number
INSTRUCTIONS: To be completed only if your valid license has been lost or destroyed.
To the Indiana Professional Standards Board / Division of Teacher Licensing:
The State of Indiana issued to __________________________________________________________________________ on
Give name exactly as it appears on license
________________________________, 19_______, a ________________________________________________________
Serial Number _____________________ of Grade ______________, on the Basis of ________________________________
with the Expiration Date of ______________________________________________. The license has been lost or destroyed.
To the best of my knowledge, it was lost or destroyed in the following manner:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
I hereby swear (or affirm) that the above statements are true to the best of my knowledge and belief. I further agree that
should the original license be found, it will be returned for cancellation.
Signature of applicant
Address
City
State
ZIP code
Subscribed and sworn to before me this _______ day of ________________________________, 19 ______.
Signature of Notary Public
Date commission expires
Typed or printed name of Notary Public
County of residence
Must include Notary seal
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