State Form 45303 - Application For Examination For Barber Instructor Registration - Indiana Professional Licensing Agency
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1
2APPLICATION FOR EXAMINATION FOR
INDIANA PROFESSIONAL LICENSING AGENCY
BARBER INSTRUCTOR REGISTRATION
302 WEST WASHINGTON STREET, ROOM E034
State Form 45303 (R3/6-98)
INDIANAPOLIS, INDIANA, 46204-2700
Approved by State Board of Accounts 1998
TELEPHONE: (317) 232-2980
CONTROL NUMBER
INSTRUCTIONS:
Application must be accompanied by the $50.00 (Fifty dollars)
examination fee and a photograph bearing your signature
Name of applicant (please print or type):
Address (number and street):
City/state/ZIP code:
Telephone number:
Social Security number:
Barber license number:
*This agency is requesting the disclosure of your Social Security number in accordance with IC 4-1-8-1. Disclosure is mandatory; this
record cannot be processed without it.
EDUCATIONAL PREREQUISITES
Please check one:
High school graduate
Date of graduation:
High school equivalency certificate (GED)
Date of GED certificate:
INSTRUCTOR TRAINING/EXPERIENCE EQUIVALENT
Have you completed the instructor education?
Name of school:
Date of enrollment:
Date of graduation:
Location of school:
OR
Have you had five (5) years full-time experience as a barber?
Dates of licensure:
To:
From:
Barber shop name(s):
(Experience equivalent statute expires July 1, 2001. Applicants filing after July 1, 2001 will be required to complete the education)
DISCLOSURE OF CONVICTION RECORD
Have you ever been convicted of a felony?
Yes
No
If you have been convicted of a felony, please include a written explanation and copies of court documents.
VERIFICATION AND SIGNATURE/NOTARY STATEMENT
I do hereby certify and declare that I will abide by and obey all provisions of the law and rules adopted by the board. I hereby certify that I completed this
application and that the answers appearing herein are true and correct to the best of my knowledge and belief.
Printed or typed name of applicant:
Signature of applicant:
Printed or typed name of Notary Public:
Signature of Notary Public:
County of residence:
Date commission expires:
Date subscribed and sworn to Notary Public:
SEE REVERSE SIDE
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