Form 15969 - Application For Examination For Cosmetologist, Manicurist, Esthetician, Or Electrology License Page 2

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AFFIDAVIT

I do hereby certify and declare the certification of education to be a correct and accurate record for the student indicated above and that the student meets

the graduation requirements pursuant to the State Board of Cosmetology Examiners statutes and rules. I understand that providing fraudulent information

may be grounds for refusal to issue the license for which is being applied and disciplinary action against the cosmetology school license.

STATE OF _______________________________

SS:

COUNTY OF _____________________________

Subscribed and sworn to before me this ____________ day of __________________________________________, ____________.

Signature of school director / instructor

Date subscribed and sworn to Notary Public (month, day, year)

Printed name of school director / instructor

Signature of Notary Public

County of residence

Printed name of Notary Public

Date commission expires (month, day, year)