State Form 49638 - Application For Activation Of A Cosmetology Professional License - Indiana Professional Licensing Agency

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APPLICATION FOR ACTIVATION OF A
INDIANA PROFESSIONAL LICENSING AGENCY
COSMETOLOGY PROFESSIONAL LICENSE
302 W. Washington Street, Room E034
Indianapolis, Indiana 46204
State Form 49638 (3-00)
(317) 232-2980
INSTRUCTIONS: 1. Complete the entire form.
2. Attach copies of your certificates of completion for sixteen (16) hours of continuing education.
APPLICANT INFORMATION
Name of applicant
License number
Resident address (number and street, city, state, ZIP code)
Telephone number
(
)
Signature of applicant
Date (month, day, year)
APPLICATION FOR ACTIVATION OF A
INDIANA PROFESSIONAL LICENSING AGENCY
COSMETOLOGY PROFESSIONAL LICENSE
302 W. Washington Street, Room E034
Indianapolis, Indiana 46204
State Form 49638 (3-00)
(317) 232-2980
INSTRUCTIONS: 1. Complete the entire form.
2. Attach copies of your certificates of completion for sixteen (16) hours of continuing education.
APPLICANT INFORMATION
Name of applicant
License number
Resident address (number and street, city, state, ZIP code)
Telephone number
(
)
Signature of applicant
Date (month, day, year)

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