Looking for a Alaska Legal Forms And Templates? Download it for free!

Form Bah - Barber And Hairdresser Application - Alaska Department Of Community And Economic Development Page 3

State of Alaska

Department of Community and Economic Development

Division of Occupational Licensing

Board of Barbers and Hairdressers

333 Willoughby, 9th Floor

P.O. Box 110806

Juneau, Alaska 99811-0806

(907) 465-2547

E-mail: license@dced.state.ak.us

STATEMENT OF RESPONSIBILITY

(Only to be used if applying for a temporary license while awaiting examination)

Date:

To Board of Barbers and Hairdressers:

, am willing to assume the full responsibility of supervising

(who is submitting an application for examination in the

practice of

. The supervision will take place at:

Name of Shop

located at

Mailing Address:

This supervision will be held in compliance with the statutes and regulations set forth by the Board of Barbers and

Hairdressers. I am currently licensed as a

, Alaska License Number

I understand that the above-named applicant must work under my direct supervision and within my physical presence.

I further understand that the temporary license is valid for 120 days from date of issue and is nonrenewable. If the

applicant fails the examination and is not eligible to receive licensure within the 120 days of the temporary license period,

the applicant will not be able to continue practicing.

I certify under penalty of unsworn falsification that the above information is true and correct.

Signature

SUBSCRIBED AND SWORN before me, this ______ day of

, at

City

State

Notary Public

NOTARY SEAL

My Commission Expires:

Please return completed form to:

Department of Community and

Economic Development

Division of Occupational Licensing

P.O. Box 110806

Juneau, AK 99811-0806

08-4193b (Rev. 2/01)

Form Bah - Barber And Hairdresser Application - Alaska Department Of Community And Economic Development Page 3