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State Form 49529 - Application For Cosmetology Continuing Education Instructor - 2000 Page 2

Outline in detail all teaching experience:

Outline in detail the qualifications which demonstrate your expertise in the cosmetology profession topics you will be teaching:

Have you attended an instructor class, seminar, or workshop in the last five years?

Yes

If Yes, indicate the approximate date, type of course, and sponsor / provider:

Are you currently licensed as a cosmetology professional?

Yes

If Yes, indicate the state you are licensed in, your license number, and length of time actively licensed:

Length of time actively licensed

State

License number

Have you ever had a cosmetology professional license or any other license to practice in another profession denied, restricted, suspended, or

revoked?

Yes

If Yes, explain on a separate sheet of paper.

Is there any disciplinary action pending against you by a cosmetology board or licensing agency?

Yes

If Yes, explain on a separate sheet of paper.

I, the undersigned, certify that the information given in this application is correct to the best of my knowledge.

Signature of instructor

Date (month, day, year)

FOR OFFICE USE ONLY

Approved

Tabled

Denied

Board comments:

Board signature

State Form 49529 - Application For Cosmetology Continuing Education Instructor - 2000 Page 2