Renewal Document for: Provisional Barber and Barber, Beauty ... - Indiana

[Pages:1]Renewal Document for: Provisional Barber and Barber, Beauty Culture Instructor, Provisional Cosmetologist and Cosmetologist, Provisional Electrologist and Electrologist, Provisional Esthetician and Esthetician, Provisional Manicurist

and Manicurist Licenses

Renew online, now using the Access Indiana single sign-on at mylicense.. To renew by mail send this document with the renewal fee of $40.00 to IPLA. Make check or money order payable to `Indiana Professional Licensing Agency'. If this document is postmarked after your license expires you must include a $50 late fee if renewing less than three years after your expiration date; or a $40 reinstatement fee if renewing more than three years after expiration date. The late fee and reinstatement fee are in addition to your renewal fee. If you indicate you are a qualified alien as defined under 8 U.SC. ? 1641 and not a U.S. citizen, please provide documentation from USCIS that shows proof of your qualified alien status.

LICENSEE INFORMATION: Provide a current phone number and email address

Enter Licensee Name

Enter License Number

Enter Expiration Date

Renewal Fee

Enter Address

Enter Phone Number

Enter Email Address

RENEWAL QUESTIONS

1. Since you last renewed, has any professional license, certificate, registration, or permit you hold or have held been disciplined or are formal charges pending in any state or U.S. territory?

YES NO

2. Since you last renewed, have you been denied a license, certificate, registration, or permit in any state or U.S. territory?

YES NO

3. Since you last renewed, and except for minor violations of traffic laws resulting in fines and arrests or convictions that have been expunged by a court, have you been arrested, entered into a diversion agreement, been convicted of, pled guilty to, or pled nolo contendere to any offense, misdemeanor, or felony in any state or U.S. territory?

YES NO

4. Pursuant to IC 12-32-15 and IC 12-32-1-6, I swear under the penalty of perjury that I am a United States Citizen.

YES NO*

ADDITIONAL INFORMATION

After confirming your license has been renewed at , you may print a free license card or order

one from our website at pla/license.htm.

LICENSEE AFFIRMATION

I hereby swear or affirm under the penalties of perjury that the information provided here is true and correct to the best of my

knowledge.

Signature of Licensee

Date (month, day, year)

*If you indicate you are not a US Citizen, please provide documentation from USCIS that shows proof of your qualified alien (as defined under 8 U.SC. ? 1641) status or documentation indicating you are authorized by the federal government to work in the United States.

Visit pla. for additional information regarding your license. If you have any questions for the State Board of Cosmetology and Barber Examiners please email pla12@pla. or call

317-234-3031.

Renewal Fee

FOR OFFICE USE ONLY Receipt No.

Date

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