Form Ci-37 - Application For Instructor Licensure
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2IDAHO STATE BOARD OF COSMETOLOGY
Bureau of Occupational Licenses
1109 Main Street, Suite 220
Boise, Idaho 83702-5642
APPLICATION FOR INSTRUCTOR LICENSURE
Complete this form by providing the requested information (please print & note the attached instructions). Your signature must be
notarized and the appropriate fees must be attached. Submit the completed form to the address noted above.
I hereby submit my qualifications and make application for a license to practice as an instructor of:
[ ]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
(Non-Idaho licensees must attach proof of age. A copy of your birth certificate, passport, military ID, or driver’s license is acceptable.)
4. Social Security No. ______-____-______ Home phone number (____)___________ E-mail __________________
5. Are you currently licensed in Idaho to practice cosmetology wholly or in part?
[ ] Yes [ ] No
(If Yes, attach a copy of your license and continue below. If No, complete the attached addendum and continue below.)
6. Do you have practical experience under licensure?
[ ]Yes
[ ]No
(If yes, please attach a detailed statement of your experience, noting the names and addresses of the businesses in which you gained
your experience and the dates of experience for each business listed.)
7. Have you completed 12 semester college credits or the approved equivalent (see Rule 600)?
[ ] Yes [ ] No
(If Yes, attach college transcripts or verification of completion of 168 clock hours of teaching seminars.)
8. Are you currently licensed to practice as an instructor in any other state?
[ ] Yes [ ] No
(If Yes, certification of licensure must be received directly from the licensing authority before your application will be processed.)
9. 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.)
10. 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 ________________________________________
CI-37 revised 08/00
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