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State Form 45245 - Application For Examination For Beauty Culture Instructor License Page 2

PART E - STATEMENT / NOTARY CERTIFICATE

STATEMENT

Have you ever committed an act for which you could be disciplined under IC 25-8-14?

Yes

If the answer is “Yes”, please describe the act on a separate sheet and attach to this application.

Have you ever been convicted, pled guilty or nolo contendere to any misdemeanor or felony in any state?

Yes

If the answer is “Yes”, please describe the act on a separate sheet and attach to this application.

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)

TRANSCRIPT OF INSTRUCTOR TRAINING

(to be completed by the Cosmetology School)

Date of enrollment (month, day, year)

Date of graduation (month, day, year)

Practical Examination Grade

Total hours obtained

I do hereby certify and declare the transcript of training to be a correct and accurate record of the student enrolled at the school of

cosmetology named below, and meets the requirements of the State Board of Cosmetology and Barber Examiners.

Date (month, day, year)

Printed name of student

Signature of school official

Name of cosmetology school

License number

Printed name of school official

COSMETOLOGY SCHOOL NOTARY CERTIFICATE

STATE OF ___________________________________

}

SS:

COUNTY OF _________________________________

Subscribed and sworn to before me, this _________ day of _____________________________________, 20_________.

Signature of Notary Public

County of residence

Typed or printed name of Notary Public

Date commission expires (month, day, year)

Affix School Seal Here

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State Form 45245 - Application For Examination For Beauty Culture Instructor License Page 2