Fillable Form 47871 - Proof Of Licensing printable pdf download

Form 47871 - Proof Of Licensing

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INDIANA DEPARTMENT OF EDUCATION

PROOF OF LICENSING

OFFICE OF EDUCATOR LICENSING AND DEVELOPMENT

151 West Ohio Street

State Form 47871 (R6 / 4-09)

Indianapolis, IN 46204

Approved by State Board of Accounts, 2005

Toll Free: 1-866-542-3672

Fax: (317) 232-9023

INSTRUCTIONS:

1. To be completed only if your valid license has been lost or destroyed.

2. Attach to a renewal or duplicate application.

To the Office of Educator Licensing and Development / Public and Agency Support Services:

The State of Indiana issued to _______________________________________________________________________________________________ on

Give name exactly as it appears on license

________________________________, __________, 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 (number and street, city, state, and ZIP code)

E-mail address

Subscribed and sworn to before me this ___________________________ day of _________________________, _______________.

Signature of Notary Public

Date commission expires (month, day, year)

Typed or printed name of Notary Public

County of residence

Must include Notary seal