Fillable Application for Registration as a Student (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application for Registration as a Student (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Cosmetology and Hairstyling
124 Halsey Street, 6th Floor, P.O. Box 45003
Newark, New Jersey 07101
(973) 504-6400
Application for Registration as a Student
Transfer or Reregistration Students Only
Date : ____________________________
There is a nonrefundable fee of $5.00 to register as a student. The check or money order should be made out to the State of
New Jersey and it must be submitted with this application (applicants should understand that if the registration fee is paid with
a personal check, and if the check is returned by the bank due to insufcient funds, the next step in the registration process will
be delayed until the fee is paid). When you have completed half of your training, you will be required to submit an additional
payment of $5.00 for your student permit.
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records
Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: ________________________
Month Day Year
Place of birth: _______________________
City State Country
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: _____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Business: ___________________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of
your head and shoulders, taken
within the past six months.
A photo is required with each
application.
Staple the photo here.
FOR OFFICE USE ONLY
Original Student
Registration No. __________________
Student
Re-Registration No. _______________
Type of coursework student will be
pursuing: (check one)
Cosmetology & Hairstyling
Manicuring
Skin Care Specialty
Barbering
Beauty Culture
Please provide a copy of your birth certicate, passport or valid
New Jersey driver’s license with this application.
3. SocialSecurityNumber
IfyouwereissuedaSocialSecurityNumberoranIndividualTaxpayerIdenticationNumber,youmustprovideittothe
BoardorCommittee.Failuretodosomayresultindenialoflicensure/certication/reinstatement/reactivation.
*SocialSecurityNumber: __________-__________-__________
*IndividualTaxpayerIdenticationNumber: __________-__________-__________
*PursuanttoN.J.S.A.54:50-24et seq. ofthe New Jerseytaxation law, N.J.S.A.2A:17-56.44eof theNew JerseyChild
EnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommittee
isrequiredtoobtainthisinformation.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovidethis
informationto:
(For healthcare-related boards, the following a, b and c entries apply. For boards not related to healthcare, only the a and
b entries apply.)
 a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurpose
ofreviewingcompliancewithStatetaxlawandupdatingandcorrectingtaxrecords;
b. theProbationDivisionoranyotheragencyresponsibleforchild-supportenforcement,uponrequest;and
c. theNationalPractitionerDataBankandtheH.I.P.DataBank,whenreportingadverseactionsrelatingtohealth
careprofessionals.
4. Citizenship/ImmigrationStatus
FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualied
aliens.Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigration
status.If youareanAmericancitizen,pleaseenclosea copyofyourbirth certicateor U.S.passport.Ifyouare not
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. StudentLoan
Areyouindefaultinregardtoanystudentloanobligation(s)? Yes No
If“Yes,”youmustobtaindocumentaryevidencethatyouhavereachedanarrangementwiththebankorwiththeentitythatissued
yourstudentloan,fortheeventualrepaymentoftheloan.Youwillnotbeabletoobtainalicenseorcerticateunlessyouprovidethe
requireddocumentsconcerningtheplanforrepaymentofyourstudentloan.
6. ChildSupport(You must answer a, b, c and d.)
Pleasecertify,underpenaltyofperjury,thefollowing:
a. Doyoucurrentlyhaveachild-supportobligation? Yes No
(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No
(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No
c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No
d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No
InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsathroughdmayresultindenialof
licensureorcertication.Furthermore,anyfalsecerticationoftheabovemaysubjectyoutoapenalty,including,butnot
limitedto,immediaterevocationorsuspensionoflicensureorcertication.
 ___________________________________ ___________________________________ ________________________

Applicant’sname(pleaseprint) Applicant’ssignature Date
click to sign
signature
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7. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
8. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.) Yes No
Yes No
9. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea
of guilty, non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury.
explanation. (Attach additional sheets of paper to this application.)
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
Yes No
10. Have you previously applied for a cosmetology/hairstyling, beauty culture, barbering, skin care specialty or manicuring
license in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
__________________________________________________________________________________
If “Yes,”when and where?
state, the District of Columbia or in any other jurisdiction? Yes No
11. Do you currently hold, or have you ever held, a professional or occupational license or certicate of any kind in New Jersey, any other
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license was issued under a
different name, please provide that name.
_____________________ _______________________ ____________________________ ____________________
Date issued/expiredType of license or certicate Number State or jurisdiction that issued the license or certicate
_____________________ _______________________ ____________________________ ____________________
Date issued/expiredType of license or certicate Number State or jurisdiction that issued the license or certicate
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
Yes No
12. Have you ever held a temporary license or limited permit in New Jersey, any other state, the District of Columbia or in any
other jurisdiction?
If “Yes,” list the date of issuance and expiration and the jurisdiction where the temporary license or limted permit was granted.
_____________________ Expiration date _____________________ Jurisdiction______________________
Date of issuance
13. Have you ever been cited for disciplinary reasons or denied a professional or occupational license or certicate of any kind
in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
14. Have you ever had a professional or occupational license or certicate of any type suspended, revoked or surrendered in
New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
15. Has any action (including the assessment of nes or other penalties) ever been taken against your professional or occupational
practice by any agency or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
16. Have you ever been named as a defendant in any litigation related to the practice of cosmetology/hairstyling, beauty culture,
barbering, manicuring or skin care specialty or other professional or occupational practice in New Jersey, any other state,
the District of Columbia or in any other jurisdiction? Yes No
17. Are you aware of any investigation pending against a professional or occupational license or certicate issued to you by a professional
or occupational board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
18. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any
other jurisdiction? Yes No
19. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional
or occupational group related to the practice of cosmetology/hairstyling, beauty culture, barbering, manicuring or skin care
specialty or other professional or occupational practice in New Jersey, any other state, the District of Columbia or in any
other jurisdiction? Yes No
If the answer to any of the above questions, numbers 13 through 19, is “Yes,” provide a complete explanation of the
circumstances leading to the action, and any supporting documentation, on separate sheets of paper.
_________________________________________________________________
Middle initialLast name First name
Education
1. Are you enrolled in high school? Yes No
If “Yes,” how many years of high school have you completed? _______________
Also, if “Yes,” please provide the name and address of the high school you are attending.
______________________________________________________________________________________
Name of school
_______________________________________________________________________________________________________
Stree t address City State ZIP code
2. If the answer to question #1 above is “No,” are you attending a program to earn a G.E.D. certicate? Yes No
If “Yes,” please provide the name and address of the school/institution offering the G.E.D. program.
_______________________________________________________________________________________________________
Name of school/institution
_______________________________________________________________________________________________________
Stree t address City State ZIP code
3. When do you expect to receive your high school diploma or G.E.D. certicate? ___________________________________
Month Year
4. Have you attended a school of cosmetology and hairstyling, manicuring, barbering, skin care specialty, beauty culture or
other vocational school? Yes No
If “Yes,” provide the name and address of the school, the dates you attended, the number of hours you’ve completed and
indicate whether you have graduated.
_______________________________________________________________________________________________________
Name of school
_______________________________________________________________________________________________________
Stree t address City State ZIP code
Dates attended: From ________________ To _________________
Did you graduate? Yes No No. hours completed ___________________
CERtIFICatION
I, _______________________________________________________ , in making this application to the New Jersey State Board of
Cosmetology and Hairstyling to register as a student, certify that I am the applicant and that all of the information provided in
connection with this application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies
or failure to make full disclosures may be deemed sufcient to deny my registration as a student by the Board.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualifications for registration. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requestedbytheBoard.
Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymeare
willfullyfalse,Iamsubjecttopunishment.
__________________________________ _________________________________________
Date Signatureofapplicant
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Cosmetology and Hairstyling
124 Halsey Street, 6th Floor, P.O. Box 45003
Newark, New Jersey 07101
(973) 504-6400
Certication of
Cosmetology and Hairstyling School
I hereby certify that the applicant herein, _______________________________________________________________________ ,
First name Middle initial Last name
in our opinion, meets all of the requirements governing the New Jersey State Board of Cosmetology and Hairstyling in
accordance with the Revised Statutes of New Jersey (N.J.S.A. 45:5 B-1 et seq.), to be accepted to be registered as a student by
the Board.
The applicant enrolled in our school on______________________________________ as a Full-time Part-time student.
Month Day Year
Monday __________ Tuesday __________ Wednesday __________ Thursday __________ Friday _________ Saturday ______
(Designate the applicant’s hours of attendance above, e.g. 9:00 - 5:00)
Cosmetology & Hairstyling Brush-Up Manicuring Skin Care Specialty
Teacher’s Program Barbering Beauty Culture
Post-Graduate English Non-English ________________________________________
Specialty language
To be admitted to the New Jersey State Board of Cosmetology and Hairstyling examination, the student must be at least 17 years
of age, have completed the required hours of training for the license sought and have completed high school or the equivalent.*
School name ______________________________________________________________________________
Address ______________________________________________________________________________
Street address
______________________________________________________________________________
City County ZIP code
Permit / License No. ___________________________________
___________________________________ ___________________________________
Print name of Principal or Supervisor Signature of Principal or Supervisor
* To obtain a cosmetology and hairstyling license, the student must complete a 1,200-hour cosmetology and
hairstyling course.
* To obtain a beauty culture license, the student must complete a 1,100-hour beauty culture course.
* To obtain a barbering license, the student must complete a 900-hour barbering course.
* To obtain a skin care specialty license, the student must complete a 600-hour skin care specialty course.
* To obtain a manicuring license, the student must complete a 300-hour manicuring course.
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Application for Registration as a Student (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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