State Form 43716 - Monthly Verified Report - Cosmetology School
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PROFESSIONAL LICENSING AGENCY
MONTHLY VERIFIED REPORT - COSMETOLOGY SCHOOL
402 West Washington Street, Room W072
State Form 43716 (R3 / 5-08)
Indianapolis, IN 46204-2246
T elephone: (317) 234-3031
820 IAC 4-1-10 (due 15th of each month)
Date of filing (month, day, year)
School license number
Name of school
Street address (number and street)
City
State
ZIP code
Telephone number
E-mail address
(
)
LAST DAY OF
STATUS
STARTING DATE
COURSE
TUITION
HOURS
ATTENDANCE
NAME OF STUDENT
CODE*
(month, day, year)
CODE**
OWED
ACCRUED
(month, day, year)
**
*
N = New
Course Codes:
ES = Esthetics
Status Code:
G = Graduated
EL = Electrology
C = Cosmetology
DO = Dropout
M = Manicure
S = Shampoo
I = Instructor
AFFIDAVIT
I certify that I personally completed this report 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 disciplinary action against the license of this school.
Signature of preparer
Date (month, day, year)
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