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STUDENT REGISTRATION FORM

(page 2 of 2)

AFFIDAVIT

I hereby certify under oath that I have reviewed the requirements for training and understand that I may not practice

independently and must receive all training under the immediate personal supervision of a licensed instructor. I further

certify that I do not have any infectious or contagious disease which may pose a threat to the general public and that the

information provided on and attached to this application is true and accurate to the best of my knowledge and belief.

I hereby authorize and direct any person, agency, firm, or other entity to release to the Bureau of Occupational Licenses or

its identified agent any and all information, communications recommendations, reports, records, statements, or

disclosures, whether public, privileged or confidential, that may relate to my professional qualifications or credentials or

that may have bearing on my eligibility for licensure.

_____________________________________________________

Signature of applicant

State of ______________, County of _________________, ss.

Subscribed and sworn before me this ______ day of _______________________, 20 _____.

(seal)

______________________________________________________

Notary Public official signature

residing at_____________________________________________

my commission expires___________________________________

SCHOOL AFFIDAVIT

I certify that I have reviewed the requirements for training and understand that a student may not practice independently

and must receive all training under the immediate personal supervision of a licensed instructor. I further certify that I

agree to comply with all Cosmetology laws and rules concerning training and that any failure to comply with those

requirements may result in action against any personal or facility license I may hold.

I further certify that the information provided on and attached to this application is true and accurate to the best of my

knowledge and belief.

I certify that I am an agent of the aforementioned school and that the named applicant is being registered within five (5)

days of beginning his/her training. I further certify that I have received and have on file acceptable documentation that the

applicant is not less than 16 ½ years of age and that the applicant has met the 10

grade education requirement.

__________________________________________________________

Signature of school agent

State of ______________, County of _________________, ss.

Subscribed and sworn before me this ______ day of _______________________, 20 _____.

(seal)

__________________________________________________________

Notary Public official signature

residing at_________________________________________________

my commission expires_______________________________________

BOL-COS-CS-59-revised 12/00

Form Bol-Cos-Cs-5 - Student Registration Form - Idaho State Board Of Cosmetology Bureau Of Occupational Licenses Page 2