State Form 45303 - Application For Examination For Barber Instructor Registration

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APPLICATION FOR EXAMINATION FOR
STATE BOARD OF COSMETOLOGY AND BARBER EXAMINERS
BARBER INSTRUCTOR REGISTRATION
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
State Form 45303 (R7 / 5-11)
Indianapolis, Indiana 46204
Approved by State Board of Accounts, 2011
Telephone: (317) 234-3031
E-mail: pla12@pla.IN.gov
INSTRUCTIONS:
1. Please type or print legibly.
2. Include a photograph of yourself.
3. Include your examination fee (call or visit our website for current fees).
* Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.
FOR OFFICE USE ONLY
Application fee
Receipt number
Date fee paid (month, day, year)
License number issued
Date license issued (month, day, year)
DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant
Social Security number *
Address (number and street, city, state, and ZIP code)
Telephone number
E-mail address
Barber license number
(
)
EDUCATIONAL PREREQUISITES
Please check one
Date of graduation or GED certificate (month, day, year):
High school graduate
High school equivalency certificate (GED)
INSTRUCTOR TRAINING
Have you completed the instructor education?
Date of enrollment (month, day, year)
Date of graduation (month, day, year)
Yes
No
Name of school
School license number
Location of school (number and street, city, state, and ZIP code)
DISCLOSURE OF CONVICTION RECORD
Have you ever been convicted of a crime?
If you have been convicted of a crime, please include a written explanation and copies of court documents.
Yes
No
VERIFICATION AND SIGNATURE
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.
Signature of applicant
Date (month, day, year)
CERTIFICATE OF TRAINING - THIS SECTION TO BE COMPLETED BY THE BARBER SCHOOL ON BEHALF OF THE EXAMINATION APPLICANT
I hereby certify that ________________________________________________ has completed nine hundred (900) hours of instructor training and has
(name of applicant)
graduated from the ________________________________________________ School of Barbering.
(name of school)
Date enrolled (month, day, year)
Date graduated (month, day, year)
Did this student transfer from another barber school?
Yes
No
Written exam grade
Practical exam grade
Signature of school director / instructor
Printed name of school director / instructor
Date (month, day, year)
NOTARY CERTIFICATE
STATE OF _______________________________
COUNTY OF _____________________________
I ________________________________________________, having been duly sworn on oath, say that I am the above named school director / instructor,
(name of school director / instructor)
that I have personally prepared the foregoing certificate of training, and that the same is true to the best of my knowledge and belief.
Signature of school director / instructor
Printed name of school director / instructor
Date subscribed and sworn to Notary Public (month, day, year)
Signature of Notary Public
Printed name of Notary Public
Date commission expires (month, day, year)

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