State Form 26770 - Application For Barber Shop License

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STATE BOARD OF BARBER EXAMINERS

APPLICATION FOR BARBER SHOP LICENSE

Reset Form

PROFESSIONAL LICENSING AGENCY

402 West Washington Street, Room W072

State Form 26770 (R6 / 6-08)

Indianapolis, Indiana 46204

Approved by State Board of Accounts, 2008

Telephone: (317) 234-3031

INSTRUCTIONS:

Please type or print.

Include the license fee (call or visit our website for current fees).

Barber shop must be ready to open at the time this application is filed.

The barber shop license must be posted in the shop where it is visible to the public.

Barber licenses must be posted in the work stations and be visible to the public.

* 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

Application fee

Date fee paid (month, day, year)

Receipt number

License number issued

Date license issued (month, day, year)

License obtained by

DO NOT WRITE ABOVE THIS LINE

Name of barber shop

Federal identification number or Social Security number *

Shop address (number and street, city, state, and ZIP code)

Name of shop owner (individual, partner, or officer)

Social Security number *

Home address (number and street, city, state, and ZIP code)

Home telephone number

Business telephone number

E-mail address

(

)

(

)

If the barber shop is a partnership or corporation, list the partners of the partnership or the officers of the corporation.

NAME

TITLE

ADDRESS

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

Pursuant to IC 25-7-1-1 (3) the barber shop will at all times be operated under the personal supervision and management of a registered barber.

Name of registered barber

Barber license number

License date of expiration (month, day, year)

Shop hours

Days open (check all that apply)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

AFFIDAVIT

I (or we) will operate this establishment in compliance with the rules governing the sanitary requirements of barber shops as required by the State Board

of Barber Examiners, and ensure that all employees comply with all requirements. (If barber shop is owned by a corporation or partnership, this application

must be signed by an officer of the corporation or a partner of the partnership.)

Have you, or an officer or a partner, ever committed an act for which you could be disciplined under IC 25-7-1-16.1?

Yes

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

I certify that I personally completed this application and that the information appearing hereon is 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 / corporate officer / partner

Date (month, day, year)