State Form 47393 - Application For Tanning Facility License

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APPLICATION FOR TANNING FACILITY LICENSE

PROFESSIONAL LICENSING AGENCY

402 West Washington Street, Room W072

State Form 47393 (R2 / 7-08)

Indianapolis, IN 46204-2700

Approved by State Board of Accounts, 2008

Telephone: (317) 234-3031

INSTRUCTIONS: This application must be completed in its entirety. Call or visit our website for current fees.

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

LICENSE NUMBER ISSUED

DATE LICENSE

DATE FEE PAID (month, day, year)

ISSUED (month, day, year)

RECEIPT NUMBER

LICENSE OBTAINED BY

DO NOT WRITE ABOVE THIS LINE

TYPE OF APPLICATION

NEW FACILITY (Fee: Call or visit our website for current fees)

TRANSFER (No fee)

GENERAL INFORMATION

Name of tanning facility

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

E-mail address

Number of tanning devices

Number of facilities owned

Telephone number

(

)

INFORMATION ABOUT THE OWNER

Name of owner

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

Telephone number

Social Security number

(

)

Tanning Equipment Registration: The applicant shall only use tanning equipment manufactured in accordance with specifications set forth in 21 Code of

Federal Regulations, Part 1040, Section 1040.20, "Sunlamp Products and Ultraviolet Lamps Intended For Use in Sunlamp Products." If a tanning device

is deleted and / or added, notify the Agency immediately.

ADDITIONAL DEVICES MAY BE SPECIFIED ON BACK

UNIT TYPE

MANUFACTURER

MODEL

SERIAL

YR. / MO. MFGD.

BULB TYPES

BED

BOOTH

Pursuant law, the applicant certifies he/she has read and understands the requirements of the law, that all information contained herein is true and correct

to the best of his/her knowledge. 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 owner

Date of application (month, day, year)

Printed name of owner