Fill - Free fillable Esthetics Application (New York State) PDF form

DOS 1323-f-a (Rev. 04/18) Page 1 of 7

New York State

Department of State

Division of Licensing Services

Appearance Enhancement

P.O. BOX 22049

Albany, NY 12201-2049

Customer Service: (518) 474-4429

www.dos.ny.gov

Esthetics Application

For a faster and easier process, the Division of

Licensing Services encourages applicants to apply

online. Using online services provides a quicker

turnaround time on your application and updates and it

allows you to view and access your license records

throughout the license process.

Visit our website at: www.dos.ny.gov

Please see the online section of these instructions for

more information.

Read the instructions carefully before completing the

application. All fields are mandatory, incomplete

applications will be returned, delaying licensure. Any

omission, inaccuracy or failure to make full disclosure in

an application or supporting documentation may be

deemed sufficient reason to deny a license, or, if a license

is issued could result in the suspension or revocation of a

license.

What does the practice of Esthetics cover?

The practice of Esthetics means providing services for a fee or any

other consideration to enhance the appearance of the face, neck,

arms, legs, or shoulders of a human being by the use of compounds

or procedures including makeup, eyelashes, depilatories, tonics,

lotions, waxes, or sanding and tweezing. They may be performed by

manual, mechanical, chemical or electrical means and instruments,

but shall not include the practice of electrology.

Who must apply for an Esthetics license?

Any person practicing Esthetics as described above is required by

law to have an Esthetics license. An Esthetics license will not permit

you to operate a business; a separate business application must be

completed and a separate business license obtained.

What qualifications and supporting documents do I

need to apply for licensure?

If you are at least 17 years old, you may apply for an Esthetics

license based on:

1) New York State Education and Examinations (eligible for

temporary license)

You must complete a 600 hour approved course of study and pass

both the New York State written and practical examinations to get

a license to operate in this state.

As proof of successful completion of schooling, you must have

the Affirmation of New York State Approved Schooling

section of the application completed by your school director.

For an online application using NYS License Center, you must

enter the curriculum code listed on your school certificate.

Schools participating in the online certification program will

affirm the completion of the course for the student through NYS

License Center. For schools that are not participating in the

online certification program, you must upload your school

certificate when you have reached the “Affirmation of NYS

Schooling” section of the online application. The system will

notify you which method is required based on the curriculum

code selected.

After your application is reviewed and accepted, you will receive

an email that explains the examination process in detail.

2) Education Outside of New York State or the United States

(eligible for temporary license)

We may waive the New York State schooling requirement if you

can document an equivalent level of schooling from another state

or country. You must submit all three of the following

documents:

(1) a school certificate;

(2) a school transcript listing subjects and hours completed;

AND

(3) a current Certification of Licensure from your state board or,

if not licensed, a current Certification from your state’s

board verifying the hours claimed.

After your application is reviewed and accepted, you will also be

required to pass both the New York State written and practical

examinations to obtain an Esthetics license in this state. You will

receive information that explains the exam process in detail.

3) Experience: 5 years outside New York State

Any individual having five years of legal experience in an

occupation equivalent to esthetics may apply for a New York

Esthetics Application

DOS 1323-f-a (Rev. 04/18) Page 2 of 7

State license by submitting satisfactory evidence of education and

experience.

Within the United States experience:

(1) An original certification from the licensing agency

you were previously licensed with.

(2) Two experience statements filled out by former employers,

co-workers, clients, that can claim your experience in the

state for at least five years. These experience statements

must include EXACT dates (month and year of start of

service and month and year of end of service), location

(city, state, shop name) and specific services that you

performed.

(3) Copy of tax returns which indicate esthetics as occupation.

Outside of the United States experience:

Evidence may include but is not limited to:

(1) Official certification from the licensing authority in your

country or verification from the Consulate that a license is

not required to practice this occupation in your country.

(2) Detailed letters from employer(s) in your country

specifying EXACT dates of employment, location and

specific services that you performed.

(3) Detailed letters from your client(s), or coworker(s), in your

country specifying EXACT dates of service, location and

specific services you performed.

(4) Copy of passport which indicates esthetics as occupation,

drivers’ license, workbook with esthetics experience, or

any photo identification.

(5) Copies of course curricula and diplomas/certificates

for education completed in your country.

(6) Copy of tax returns which indicate esthetics as occupation.

After your application is reviewed and accepted, you may

obtain an Esthetics license in New York State without

examination or further education.

4) Endorsement

An applicant who holds an Esthetics license in another

jurisdiction may obtain an Esthetics license in New York through

endorsement without examination or further education. Refer to

our website www.dos.ny.gov for an Esthetics endorsement list to

determine if you qualify for licensure based on endorsement.

An applicant must submit an original certification dated within 6

months from the jurisdiction where s/he holds an equivalent

license.

5) Previous New York State Licensure

An individual who fails to file an application and fee for renewal

within five years of the expiration date cited on the individual’s

license shall be ineligible for such license until he/she passes a

written exam. Proof of previous licensure may be required.

Why do I need to provide my email address on the

paper application?

Your email address will be used to create your NYS License Center

account. Most communications will be sent via email. If you change

your email address in the future you will need to log into your

account and update it with the new email address.

How do I schedule my examination once my

application has been approved?

Scheduling exams will only be available through your online

account.

Once your application has been approved you will receive an email

notifying you that you may now schedule your exam. If you applied

online through the NYS License Center you will be able to log into

your account to schedule your examination. If you applied

submitting a paper application to the Division of Licensing Services,

the email will be sent to the email address you included in your

application. If you have indicated that you require special testing

arrangements, you will be contacted by a representative from the

Division of Licensing Services to have your examinations scheduled

for you.

Can I work before passing the state exams?

Yes. Two six-month temporary licenses are available to applicants

who want to work while completing the examination process. Only

applicants applying based on education obtained in New York State

or the United States are eligible for temporary licensure. Applicants

may apply for a temporary license renewal once they have passed the

written or practical examination. Once you pass both examinations,

a four-year license will be issued.

What are the fees and terms of licensure?

$40 - Original application license fee (for all applicants). For

those applicants who are not required to pass the

examinations (e.g., applying based on 5 years of legal

experience), this is the only fee that is required.

$10 - 6 month temporary license fee

$10 - 6 month temporary license renewal fee (separate

application)

Please Note: If applying for an original application and a temporary

license, you may submit one $50 application fee. Separate

application fees are not required.

The term of licensure is four years. The term for a temporary

license is 6 months.

$15 - Exam fee (to be collected when you schedule your

examination online)

Esthetics Application

DOS 1323-f-a (Rev. 04/18) Page 3 of 7

What forms of payment do you accept?

You may pay by check or money order made payable to the

Department of State. You may also pay by American Express,

MasterCard or Visa, using a credit card authorization form or when

applying online. Do not send cash. Application fees are

nonrefundable. A $20 fee will be charged for any check returned

by your bank.

Do I need a physical to be licensed?

Yes. You need to be examined by a physician, physician’s assistant

or nurse practitioner to apply for a license in Esthetics. Your

physician, physician’s assistant or nurse practitioner must

complete and date the Health Certification section of the application.

You must submit your application within 30 days after the

certification is signed and dated.

Child Support Statement

A Child Support Statement is mandatory in New York State (General

Obligations Law) regardless of whether or not you have children or

any support obligation. Any person who is four months or more in

arrears in child support may be subject to having his or her

business, professional and driver’s licenses suspended. The

intentional submission of a false written statement for the purpose of

frustrating or defeating the lawful enforcement of support obligations

is punishable under §175.35 of the Penal Law. It is a class E felony to

offer a false instrument for filing with a state or local government

with the intent to defraud.

Information on Online Services:

For a faster and easier process, the Division of

Licensing Services encourages applicants to apply

online. Using online services provides a quicker

turnaround time on your application and updates and

it allows you to view and access your license records

throughout the license process.

For more complete instructions and other online information see the

FAQ’s at http://www.dos.ny.gov/licensing/lc-faq.html

What transactions and information are available

online?

• Complete an initial application

• Check the status of an application

• Renew your license

• Schedule an examination and view the results

• Check the status of a license

• Amend license information

• Request a duplicate license

How do I register for an account within the NYS

License Center (NYSLC)?

In order to register for an account within the NYS License Center

(NYSLC), you must first register with My NY.gov.

If you are not currently registered with My NY.gov, go to the My

NY.gov registration site at https://aca.licensecenter.ny.gov/aca and

click on the ‘I need a NY.gov ID’ link and follow the registration for

My NY.gov. Once you are registered with My NY.gov, select the

NYS License Center option from the options available to you on My

NY.gov. In the NYS License Center, click on the ‘Account

Management’ link in the top right hand corner. Complete the

required fields and this data will pre-populate on all new applications

created using your account. Once you have completed and saved this

data, click on the ‘Home’ tab to proceed.

What if I already have a My NY.gov Account?

If you are already registered with My NY.gov, go to My NY.gov and

available to you on My NY.gov. This will create your NYS License

Center Account. In the NYS License Center, click on the ‘Account

Management’ link in the top right hand corner. Complete the

required fields and this data will pre-populate on all new application

created using your account. Once you have completed and saved this

data, click on the ‘Home’ tab to proceed.

How do I apply for a license in NYS License Center?

To apply for a license at NYS License Center, you must create an

account or login to your existing account. Follow these steps to apply

for your license online:

• Register for an Account or Login to your account (see “How

do I register for an account within the NYS License Center

(NYSLC)” above)’

• Once you are logged in to NYS License Center, on the

‘Home’ tab select ‘Apply now for a new license or permit’

• Follow the application instructions provided online

• Upload any supporting documentation

• Make payment and print confirmation page

You will be able to log in to your account and view the status of your

application.

How do I create an additional license online?

To apply for an additional license, login to your account and click on

the ‘Manage My Licenses’ tab and then select the ‘Apply now! For a

New License or Permit’ link. Read and accept the terms and

conditions and the system will guide you from there.

How do I renew a license online?

If you have an existing NYS License Center account, three months

before your license is due to expire you will receive a renewal notice

via email. The email contains a link to your account. Click on the

link and proceed through the renewal application.

If you do not have an existing account on NYS License Center, you

will receive your renewal notice via mail three months before your

Esthetics Application

DOS 1323-f-a (Rev. 04/18) Page 4 of 7

license is due to expire. This notice will contain instructions for

creating an account on NYS License Center.

What is my User ID for the online system?

When you create your account on My NY.gov, you will create a

unique user ID and use your email address. You will then be able to

access your account via user ID.

How do I update my online account information?

There are two locations you are required to update your online

account information. You need to update your data at My NY.gov

and on your NYS License Center account.

At My NY.gov, see the FAQs for information on managing your

account.

see a link titled ‘Manage My Licenses’. From there you will be able

to update your account information by completing a contact change

amendment.

I am applying online, how do I notify this department

of my physical examination?

All applicants need to be examined by a physician, physician’s

assistant or nurse practitioner to apply for a license in Esthetics. The

license application must be submitted within 30 days after an

examination by a physician, physician’s assistant or nurse

practitioner and must include their name and contact information on

the application. The Health Certification Form (DOS-1948) must be

completed and can be downloaded from the Department of State

website.

On your online application using NYS License Center, you must

utilize the information contained on the completed Health

Certification Form. You are required to enter information from this

form into the health certification fields within the system.

Please note: This completed Health Certification Form is subject to

audit by an investigator to ensure compliance with this requirement.

Evidence of this form must be maintained on your work premises for

audit purposes.

PRIVACY NOTIFICATION

Do I need to provide my Social Security and Federal

ID numbers on the application?

Yes, if you have a social security number or Federal ID number, you

are required to provide this number. If you do not have a social

security number or Federal ID number, please provide a written

explanation.

The Department of State is required to collect the federal Social

Security and Employer Identification numbers of all licensees. The

authority to request and maintain such personal information is found

in §5 of the Tax Law and §3-503 of the General Obligations Law.

Disclosure by you is mandatory. The information is collected to

enable the Department of Taxation and Finance to identify

individuals, businesses and others who have been delinquent in filing

tax returns or may have underestimated their tax liabilities and to

generally identify persons affected by the taxes administered by the

Commissioner of Taxation and Finance. It will be used for tax

administration purposes and any other purpose authorized by the Tax

Law and may also be used by child support enforcement agencies or

their authorized representatives of this or other states established

pursuant to Title IV-D of the Social Security Act, to establish,

modify or enforce an order of support, but will not be available to the

public. A written explanation is required where no number is

provided. This information will be maintained in the Licensing

Information System by the Director of Administration and

Management, at One Commerce Plaza, 99 Washington Avenue,

Albany, NY 12231-0001.

WOULD YOU LIKE TO REGISTER TO VOTE?

Please visit the NY State Board of Elections at www.elections.ny.gov/votingregister.html

or call 1-800-FOR-VOTE to request a NYS Voter Registration form.

To register online, please visit www.ny.gov/services/register-vote.

FOR OFFICE APPLICATION NUMBER FEE $40 or $50

USE ONLY AEE-A-____ - ______________

New York State

Department of State

Division of Licensing Services

Appearance Enhancement

P.O. BOX 22049

Albany, NY 12201-2049

Customer Service: (518) 474-4429

www.dos.ny.gov

Est

hetics Application

Read the

instructions

before completing this

application. You must answer each

question

and PR IN T

responses in ink

Please select one of the following qualifying choices.

I am applying for licensure ($40 application fee required) based on:

1. Ne

w York State Education and Examinations (completion of a 600 hour approved course of study)

2. Previous New York State Esthetics Licensure – License UID # Expiration Date

3. Education outside of New York State or the United States

4. Experience: 5 years outside of New York State or the United States State Country

5. Endorsement – Enter name of state

you selected choice 1, 2 or 3 from above, you may apply for a six month temporary license (requires an additional $10 fee) which allows you to

practice while taking the New York State Exams.

I am requesting a six month temporary license. ($40 + $10 = $50 application fee required)

If you selected choice 1, 2 or 3 from above, you will be emailed a link to schedule an examination once your application has been approved.

I require special testing arrangements.

If you have a

learning disability or any physical, mental or psychological disability and request special testing arrangements, you must submit a

completed “Special Testing Arrangements Request” Form (DOS-1591) with your application. You must also submit supporting

documentation from a physician, other qualified professional or evidence of prior accommodations from a school or other institution describing

your condition and an explanation of any modifications requested. Once your application has been approved, you will be contacted by a NYS

Licensing representative to schedule your examination.

Applicant Information

First Name

Last Name

Middle Name

Suffix

Home Address (provide street number and street name)

Suite, Apt., Unit

City

State

Zip+4

County Country

Mailing Address (provide PO Box here)

City

State

Zip+4

County Country

E-Mail Address

Social Security Number

Federal Taxpayer ID

Date of Birth

Home Phone

Mobile Phone

Business Phone

DOS 1323-f-a (Rev. 04/18) Page 5 of 7

Esth

etics Application

Healt

h Certification

– You must submit this application within 30 days after your physical examination.

I am a d

uly licensed physician, physician assistant or nurse practitioner and in the course of a routine examination of the person named on this

application on (Date of Physical Examination)

, I found no clinical evidence of the presence of infectious or

communicable disease which would pose a significant risk or direct threat to the health or safety of members of the public in the conduct of the

applicant’s occupation.

Print Name of Physician

Address of Practice

Physician’s Signature Date

Child S

upport Statement

By signing this application, I certify that as of the date of this application, I am not under an obligation to pay child support OR if I am under

an obligation to pay child support, I am not four or more months in arrears in the payment of child support, or I am making payments by

income execution or by court agreed payment or repayment plan or by plan agreed to by the parties or my child support obligation is the

subject of a pending court proceeding, or I am receiving public assistance or supplemental security income.

Applicant Affirmation – I affirm, under the penalties of perjury, that the statements made in this application are true and correct. I

further affirm that I have read and understand the provisions of Article 27 of the General Business Law and the rules and regulations

promulgated thereunder.

Applicant’s

ign

e Date

If you are applying based on New York State Education and Examinations, your school’s director or principal must

complete the following:

Affirmat

ion of New York State Approved School

School name

School address (provide street number and street name)

City

State

Zip+4

School Curriculum Code (Five digit numerical code assigned by NYS Department of State)

School Director’s or Principal’s name in full (print)

Title (Director or Principal)

Applicant’s name in full (print)

DOS 1323-f-a (Rev. 04/18) Page 6 of 7

Esthe

tics Application

I subscribe and affirm under the penalties of perjury that the above-named school is duly licensed pursuant to §5001 of the Education

Law and/or approved by the Board of Regents of the State of New York. The person named on this application has successfully completed a

600 approved hour course of study on (date) .

Signature of School Director/Principal Date

School

Please

remember

to include with this application any

required explanations

and

statements

along with

you

application fee (payable to NYS

Department

of State) — $50 for

application

and

temporary

license; OR $40

application only. A $20 fee will be charged for any check

returned

by your bank. If you wish

to pay by credit

car

please visit our website at www.dos.ny.gov to obtain a credit card

aut

hori

zatio

form to complete and return with this application.

It is im

portant that you notify this division of any changes to your residence and email address

you can receive renewal notices and any other notifications pertinent to your

license.

DOS 1323-f-a (Rev. 04/18)

Page 7 of 7

Become an Organ and Tissue Donor

Organ donors save lives. If you would like to be an organ and tissue donor upon your death, you may enroll in the

NYS Donate Life Registry online at www.donatelife.ny.gov/register or complete the form below. Completed forms

should be sent to the NYS Donate Life Registry by email --- Registry@donatelife.ny.gov or, mail - NYS Donate Life

Registry, 185 Jordon Road, Troy, NY 12180.

Fields with an asterisk (*) are required for enrollment. Upon receipt of your completed enrollment form, you will be

sent an email or letter confirming your enrollment and providing you with information on how to limit your donation.

I understand that by opting out of enrolling in the NYS Donate Life Registry, or skipping this question, will not impact

or impair my ability to obtain services from the New York Department of State, Division of Licensing Services.

*Last name

*First name

Middle Initial Suffix

*Address

*Apt. Number *Zip Code

*City

*Birth date / / *Gender M

MM DD YYYY

Email address

DMV or IDNYC Number

By signing below, you certify that you are:

• 16 years of age or older;

• Consenting to donate your organs and tissues for

transplantation and/or research in the event of your death;

• Authorizing the New York Department of State, Division of

Licensing Services to transfer your name and identifying

information to the NYS Donate Life Registry for

enrollment;

and

• Authorizing the Registry to give access to this information

to federally regulated organ procurement organizations

and NYS-licensed tissue and eye banks and others

approved by the NYS Commissioner of Health in the event

of your death.

*Sign *Date

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