Form C-37 - Application For Licensure printable pdf download

IDAHO STATE BOARD OF COSMETOLOGY

Bureau of Occupational Licenses

1109 Main Street, Suite 220

Boise, Idaho 83702-5642

APPLICATION FOR LICENSURE

(see instructions on reverse side)

Please complete this form by providing the requested information (please print & note the instructions on the back). Your

signature must be notarized and the appropriate fees must be attached. Submit the completed form to the address noted

above. NOTE: ANY PRACTICE PRIOR TO OBTAINING A VALID WORK PERMIT OR LICENSE IS

UNLAWFUL AND MAY RESULT IN CRIMINAL PROSECUTION AND DENIAL OF LICENSURE.

I hereby submit my qualifications and make application for a license to practice: (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.

1. Full Name (Mr., Mrs., or Ms.) _____________________________________________________________________

2. 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. See Rule 250.)

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

[ ]Yes [ ] No

(If Yes, a detailed statement, including a summary of the charges, the final order, any probation or parole documentation, and any

other relevant information must be attached.)

7. Are you or have you ever been licensed in any state to practice cosmetology wholly or in part?

[ ]Yes [ ] No

(If Yes, certification of licensure must be received directly from the licensing authority before your application will be processed.

Please review the attached addendum.)

8. Do you wish to receive a work permit?

[ ]Yes [ ] No

(An additional $10.00 permit fee must be attached. Work permits allow practice only under supervision, are issued only once and

expire upon receipt of your exam results.)

AFFIDAVIT

I hereby certify that I am the person named above and that I have no infectious or contagious disease which may pose a

threat to the general public and that I am of good moral character and temperate habits. I swear or affirm that the

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

further certify that I have reviewed and will comply with the Idaho Laws and Rules governing the practice of

Cosmetology. I further certify that I have successfully completed the required training program and have been duly

graduated. 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 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

___________

C-37 revised 10/00

Form C-37 - Application For Licensure

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