State Form 45245 - Application For Examination For Beauty Culture Instructor License
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APPLICATION FOR EXAMINATION FOR
STATE BOARD OF COSMETOLOGY AND BARBER EXAMINERS
BEAUTY CULTURE INSTRUCTOR LICENSE
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
State Form 45245 (R6 / 5-11)
Indianapolis, Indiana 46204-2246
Telephone: (317) 234-3031
Approved by State Board of Accounts, 2011
E-mail: pla12@pla.IN.gov
INSTRUCTIONS: Please type or print legibly.
*
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
DATE FEE PAID (month, day, year)
RECEIPT NUMBER
TAPE A PHOTOGRAPH HERE
THAT IS AT LEAST 2” X 3”
LICENSE NUMBER ISSUED
IN SIZE.
DATE LICENSE ISSUED (month, day, year)
LICENSE OBTAINED BY
DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
*
Name (first, middle initial, last)
Social Security number
Address (number and street, city, state, and ZIP code)
Date of birth (month,day, year)
Telephone number
E-mail address
(
)
Cosmetology license number
Date of expiration (month,day, year)
Manicurist license number
Date of expiration (month,day, year)
Electrologist license number
Date of expiration (month,day, year)
Esthetician license number
Date of expiration (month,day, year)
PRELIMINARY EDUCATION
Check the appropriate box for the number of years completed
Received GED?
Date (month, day, year)
1
2
3
4
5
6
7
8
9
10
11
12
Yes
No
PRACTICE
I have actively practiced cosmetology, esthetics, manicuring, or electrology in a salon from
to
;
Month, day, year
Month, day, year
at
;
;
Name of salon
Address of salon
;
.
Salon license number
Name of owner / manager of salon
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