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

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Application for a Student Permit (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 a Student Permit
Transfer or Reregistration Students Only
(Note: Vocational students must provide a copy of their birth certicate.)
Check all that apply: Cosmetology & Hairstyling Manicuring
Skin Care Specialty Barbering Beauty Culture
Date: ______________________________
A nonrefundable application ling fee of $5.00, in the form of a check or money order made out to the State of New Jersey,
must be submitted with this application (applicants should understand that if the application ling fee is paid with a personal
check, and the check is returned by the bank due to insufcient funds, the next step in the application process will be
delayed until the fee is paid).
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 address City State ZIP code County
____________________________________ ___________________________________
Telephone number (include area code) E-mail address
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.
Only vocational students are
required to submit a photo.
Use a staple to attach the photo.
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so may result in denial/nonrenewal of
licensure or certication.
*Social Security 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
Support 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 your Social Security number. Pursuant to these authorities, the Board or Committee is also
obligated to provide your Social Security number to:
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; and
b. the Probation Division or any other agency responsible for child support enforcement, upon request.
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 not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other 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 status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
Education and Training
1. What is the name and address of the grammar (middle) school you attended? _____________________________________
Name of school
_______________________________________________________________________________________________________
Street address City State ZIP code
2. What is the name and address of the high school you attended? _________________________________________________
Name of high school
_______________________________________________________________________________________________________
Street address City State ZIP code
3. How many years of high school have you completed? ______________
4. Have you graduated from high school? Yes No
If “No,” did you study to receive a G.E.D. certicate? Yes No
If “Yes,” please provide the name and address of the educational institution that issued your G.E.D. certicate and
the date
the
certicate was issued.
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
___________________________________
Date certicate was issued
5. What is the name and address of the cosmetology/hairstyling, beauty culture, barbering, skin care specialty or manicuring
school you are attending where you have completed the required hours of training required to obtain a student permit?*
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
* To obtain a student permit to practice cosmetology and hairstyling, you must complete 600 hours of training.
* To obtain a student permit to practice beauty culture, you must complete 550 hours of training.
* To obtain a student permit to practice barbering, you must complete 450 hours of training.
* To obtain a student permit to practice skin care specialty, you must complete 300 hours of training.
* To obtain a student permit to practice manicuring, you must complete 150 hours of training.
6. Have you previously had training as a barber, beautician, skin care specialist, manicurist or as a cosmetologist/hairstylist?
Yes No
If “Yes,” provide the name and address of the school, the dates you attended, and the number of hours you completed there.
_______________________________________________________________________________________________________
Name of school
_______________________________________________________________________________________________________
Street address City State ZIP code
Dates attended: From ____________________ To _____________________ No. hours completed ________________
Current School’s Certication
The applicant, ___________________________________________________________, has attended our school
from __________________________________ to ________________________________. He/she has completed at least
Month Day Year Month Day Year
______________ hours of instruction.
____________________________________________________________________________________________________
Name of school
____________________________________________________________________________________________________
Street address City State ZIP code
__________________________________________ ___________________________________
School administrator (please print) Signature of school administrator
Certication of Applicant
I do hereby certify that I am of good moral character. I have been informed of the minimum requirements to obtain a student
permit and understand that I must meet those requirements. I further afrm that all statements made by me on this form are true
and accurate and are made for the purpose of making application to the New Jersey State Board of Cosmetology and Hairstyling
for a student permit.
Date: ___________________________ , 20 ______ . _______________________________________
Month Day Signature of applicant
Witnessed by:
___________________________________________________________________________________________
Signature of parent or nearest kin of applicant Address ZIP code
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
Physician‘s Certicate
I hereby certify that I have examined ____________________________________________________________________________,
First name Middle initial Last name
whose address is _____________________________________________________________________________________________,
Street address City State ZIP code
on ______________________________________ and found this person to be free from any evidence of infectious, contagious
Date
or communicable diseases which could reasonably be expected to be transmitted during the course of rendering cosmetology
and hairstyling, beauty culture, barbering, skin care specialty or manicuring services.
Physician’s name ______________________________________________
Please print clearly
Date _______________________________ Physician’s signature ___________________________________________
____________________________________________________________________________________________________
Street address City State ZIP code
Form must be submitted within 3 months of physician’s signature date.
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Application for a Student Permit (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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