State Form 43493 - Application For Cosmetology Professional License By Reciprocity - State Board Of Cosmetology Examiners

APPLICATION FOR COSMETOLOGY PROFESSIONAL

STATE BOARD OF COSMETOLOGY EXAMINERS

LICENSE BY RECIPROCITY

PROFESSIONAL LICENSING AGENCY

402 West Washington Street, Room W072

State Form 43493 (R8 / 7-07)

Indianapolis, Indiana 46204

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Telephone: (317) 234-3031

Approved by State Board of Accounts, 2007

E-mail: pla12@pla.IN.gov

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

FOR OFFICE USE ONLY

Date approved by board (month, day, year)

Issuance fee

Date fee paid (month, day, year)

Receipt number

License number issued

Date license issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE

Type of license (please check one)

Cosmetologist

Esthetician

Manicurist

Electrologist

PART A - APPLICANT INFORMATION

Social Security number *

Name of applicant (last, first, middle)

Permanent mailing address (number and street, city, state, and ZIP code)

Telephone number

Date of birth (month, day, year)

E-mail address

(

)

PART B - PRELIMINARY EDUCATION

Check the number of years completed

Year

1

2

3

4

5

6

7

8

9

10

11

12

PART C - RECORD OF LICENSURE

State of original licensure

Title of original license

Number of original license

Date of issue (month, day, year)

State of current licensure

Title of current license

Number of current license

Date of issue (month, day, year)

PART D - RECORD OF TRAINING AND GRADES

Name of cosmetology school

License number

Address of cosmetology school (number and street, city, state, and ZIP code)

Dates attended (month, day, year)

T otal credit hours earned

Course completed?

Yes

No

From:

T o:

Final examination grade - practical

Final examination grade - written

Date of final examination (month, day, year)

Date of graduation (month, day, year)

PART E - SIGNATURE AFFIRMATION

1. Have you ever been convicted of an act for which you could be disciplined under IC 25-8-14 or a

Yes

No

crime that has a direct bearing on your ability to practice competently?

If yes, please attach supporting documentation relevant to the conviction.

I certify that I personally completed this application and that the answers appearing hereon are true and correct to the best of my knowledge and belief.

I understand that providing fraudulent information may be grounds for refusal to issue the license for which I am applying or for disciplinary action against

the license which may be issued.

Signature of applicant

Date (month, day, year)