Form 43716 - Monthly Verified Report-Cosmetology School July 1999

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Indiana Professional Licensing Agency
MONTHLY VERIFIED REPORT - COSMETOLOGY SCHOOL
302 West Washington Street, Room E034
Indianapolis, IN 46204-2246
State Form 43716 (R2 / 7-99)
Telephone: (317) 232-2980
820 IAC 4-1-10 (due 15th of each month)
Date of filing (month, day, year)
School license number
Name of school
Street address
City
State
ZIP code
Telephone number
Name of owner
If corporation, list officer's names
STATUS
STARTING
COURSE
TUITION
HOURS
LAST DAY OF
NAME OF STUDENT
*
DATE
**
OWED
ACCRUED
ATTENDANCE
CODE
CODE
**
*
N = New
Course Codes:
ES = Esthetics
Status Code:
G = Graduated
EL = Electrology
C = Cosmetology
M = Manicure
I = Instructor
DO = Dropout
S = Shampoo
NOTARY CERTIFICATE (Attested)
STATE OF
}
SS:
COUNTY OF
I, __________________________________________________________, being duly sworn on oath, do state that the above statements are true
to the best of my knowledge.
Subscribed and sworn to before me on this __________ day of ____________________________________, ________________.
Signature of School Manager
Signature of Notary Public
Printed or typed name of School Manager
Printed or typed name of Notary Public
Date subscribed and sworn to Notary Public
County of residence
Date commission expires
FOR OFFICE USE ONLY
Initials of data processor
Date (month, day, year)

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