Form C-37 - Application For Licensure (Page 2 of 2) in pdf

APPLICATION FOR LICENSURE

ADDENDUM

A. CHARACTER REFERENCES: All applicants must provide the names and addresses of three character references below.

_______________________________

_________________________________

_______________________________

_________________________________

_______________________________

_________________________________

B. WORK EXPERIENCE: Please list all work experience obtained under licensure. Experience obtained under a permit or

prior to being issued a license will not be considered. Include employer names, addresses, phone numbers and dates of

practice.

NAME OF SHOP _________________________________ EMPLOYERS NAME _________________________________

ADDRESS of SHOP ___________________________________________________ PHONE NO. _____________________

DATES of PRACTICE _______________________________ TO _______________________________________________

NAME OF SHOP _________________________________ EMPLOYERS NAME _________________________________

ADDRESS of SHOP ___________________________________________________ PHONE NO. _____________________

DATES of PRACTICE _______________________________ TO _______________________________________________

NAME OF SHOP _________________________________ EMPLOYERS NAME _________________________________

ADDRESS of SHOP ___________________________________________________ PHONE NO. _____________________

DATES of PRACTICE _______________________________ TO _______________________________________________

If more space is needed, attach a separate sheet of paper

_______________________________________________________________________________________________________

C. PHOTOGRAPH: All applicants must attach an original 3”X 3” bust only photograph of yourself below.

HEIGHT

_____________

WEIGHT

_____________

ATTACH PHOTOGRAPH HERE

EYE COLOR

_____________

HAIR COLOR _____________

OTHER DISTINGUISHING FEATURES

__________________________________________________

C-37 revised 10/00

Form C-37 - Application For Licensure Page 2