Form Cos-Ca-59 - Apprentice Registration Form (Page 2 of 2) in pdf

(page 2 of 2)

INSTRUCTOR AFFIDAVIT

I hereby certify under oath that I am an Idaho licensed instructor and that I have reviewed the requirements for apprenticeship training

and understand that an apprentice 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 will be present in the establishment with said

apprentice at all times. I further certify that the attached curriculum outlines and identifies the apprentice-training program that will be

provided to said apprentice.

I further affirm that I am familiar with and agree to comply with all Cosmetology laws and rules concerning apprenticeships 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.

________________________________________________________________

Signature of instructor & License #

State of ______________, County of _________________, ss.

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

(seal)

________________________________________________________________

Notary Public official signature

residing at________________________________________________________

my commission expires_____________________________________________

SALON AFFIDAVIT

I hereby certify that I am the registered owner of the aforementioned salon and that I am familiar with and agree to comply with all

Cosmetology laws and rules concerning apprenticeships 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 list below is a complete roster of all current employees of the aforementioned salon in which the apprentice

will receive training.

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.

________________________________________________________________

Signature of salon owner

Salon Name ____________________________________________ License # ________________ Phone # ____________________

e-mail ______________________________________

State of ______________, County of _________________, ss.

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

(seal)

________________________________________________________________

Notary Public official signature

residing at_______________________________________________________

my commission expires____________________________________________

EMPLOYEE ROSTER

Name _______________________________________________________________________ License # ____________

(Please attach a separate list if additional space is necessary)

COS-CA-59 revised 12/00

Form Cos-Ca-59 - Apprentice Registration Form Page 2