Form Cos-Ca-59 - Apprentice Registration Form printable pdf download

IDAHO STATE BOARD OF COSMETOLOGY

Bureau of Occupational Licenses

1109 Main Street, Suite 220

Boise, Idaho 83702-5642

(208) 334-3233

hpiippo@ibol.state.id.us

APPRENTICE REGISTRATION FORM

Complete this form by providing (please print) the requested information. The signatures of the apprentice applicant, salon owner,

and instructor must be notarized and the fee ($20.00) must be attached. Submit the completed form to the address noted above.

NOTE: THIS COMPLETED FORM MUST BE SUBMITTED TO THE BUREAU OFFICE AND THE APPRENTICE

LICENSE ISSUED BEFORE THE APPLICANT’S TRAINING BEGINS.

I hereby submit my application to be registered as an apprentice in: (please check applicable box(s)

[ ]Cosmetology

[ ]Nail Technology

[ ]Esthetics

[ ]Electrology

in the State of Idaho under the provisions of Title 54, Chapter 8, Idaho Code as amended.

Full Name (Mr., Mrs., or Ms.) _____________________________________________________________________________

Mailing address_________________________________________________________________________________________

Street

City

State

Zip

3. Place of Birth _____________________________________________________

Date of Birth _______/_______/_______

month

day

year

(Proof of age must be attached. A copy of your birth certificate, passport, military ID, or valid driver’s license is acceptable.)

4. Social Security No. ______-____-______ Home phone number (____)______________ E-mail ________________________

5. Do you have at least a tenth (10

) grade education or the equivalent?

[ ]Yes

[ ]No

(Proof of education must be attached. A copy of your high school diploma, transcript, GED, or CPAt is acceptable.)

Name of Cosmetology salon you will apprentice in and date training will begin:

__________________________________________________________________________________________________________

Name of salon

Date training begins

7. Have you ever been convicted of any State or Federal felony?

[ ]Yes

[ ]No

(If yes, please attach a detailed statement, including a summary of the charges, the final order, any probation or parole

documentation, and any other relevant information.)

8. Have you received prior cosmetology training in Idaho?

[ ]Yes

[ ]No.

(If yes, please attach the name of the school you attended, your name (if different), and the dates you attended.)

Attach an unmounted 3” X 3” bust only photograph of yourself, taken within 1 year of this application.

AFFIDAVIT

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

independently and must receive all training under the immediate personal supervision of a licensed instructor and an additional

licensee. 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 it’s

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 apprentice 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___________________________________

(page 1 of 2)

COS-CA-59 revised 12/00

Form Cos-Ca-59 - Apprentice Registration Form

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