In State Form 15969 - Application For Examination For Cosmetologist, Manicurist And Shampoo Operator License

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INDIANA PROFESSIONAL LICENSING AGENCY

APPLICATION FOR EXAMINATION FOR COSMETOLOGIST,

302 West Washington Street, Room E034

MANICURIST AND SHAMPOO OPERATOR LICENSE

Indianapolis, IN 46204-2700

State Form 15969 (R4 / 7-99)

Approved by State Board of Accounts, 1999

Please check one:

Cosmetologist

Manicurist

Shampoo Operator

INSTRUCTIONS: Submit exmination fee with application. The examination fees are: Cosmetologist: $20.00; Manicurist: $10.00; Shampoo Operator:

$20.00. CANDIDATES SHALL BE ADVISED OF LICENSE FEE WITH NOTIFICATION OF PASSING THE EXAMINATION.

Social Security number *

* Social Security number is requested by this agency in accordance with IC 4-1-8-1, and is mandatory

that it be given. Social Security numbers are available to the Indiana Department of Revenue.

PART A: IDENTIFYING INFORMATION (to be completed by applicant)

Name of applicant (first, middle initial, last)

Age

Maiden name

Date of birth (month, day, year)

Telephone number

(

)

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

County

PART B: PRELIMINARY EDUCATION

Circle the number of years completed:

Received GED?

Date (month, year)

Yes

Name of grade school:

Address (number and street, city, state, ZIP code)

Dates attended (month, year)

Graduated:

Name of high school:

Address (number and street, city, state, ZIP code)

Dates attended (month, year)

Graduated:

PART C: STATEMENT / NOTARY CERTIFICATE

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.

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.

NOTARY CERTIFICATE (SWORN OATH)

STATE OF

}

SS:

COUNTY OF

, having been duly sworn on oath, say that I am the

above-named applicant, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.

Signature of applicant

Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public