Fillable HD Demonstrator Application

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HD Demonstrator Application

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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1 of 3 rev. 12/12
The Commonwealth of Massachusetts
Division of Professional Licensure
1000 Washington Street Suite 710
Boston, MA 02118-6100
Board of Registration of Cosmetology and Barbering
www.mass.gov/dpl/boards
617-727-9940
Demonstrator’s Application
DEMONSTRATOR APPLICANTS
INSTRUCTIONS
In order to be eligible to apply for a demonstrator’s license you must have at least 3
month’s practical experience as such.
A completed application must include:
If you do not hold any license, a notarized affidavit certifying work experience for each
manufacturer or distributor must be attached to the application. This affidavit must be on the
letterhead of the company or product for which you are demonstrating.
A copy of your driver’s license or picture ID
One 2” x 2” photograph
Money order or check for $136.00 made payable to: Commonwealth of Massachusetts.
*Application fees are non-refundable.* All money orders must be signed and dated.
Any person who is registered as a hairdresser, aesthetician, operator or instructor may,
upon payment of the appropriate fee, be registered also as a demonstrator, and may
thereafter practice as such. If you hold a license in another state please attach a copy to
the application.
A person who is issued a demonstrator’s license may only perform demonstrations for
individuals in the cosmetology industry and not the general public.
Demonstrations may be performed in the following locations: in a registered shop in the
Commonwealth, at hairdressers’ trade shows or meetings in the presence of licensed
beauty shop owners and their employees, in the business quarters of distributors or supply
houses, or in schools of beauty culture with licensed instructors in attendance.
There shall be no charge for these demonstrations.
Normal application processing time for complete applications is between 3-4 weeks.
Incomplete applications can further delay processing time.
2 of 3 rev. 12/12
The Commonwealth of Massachusetts
Division of Professional Licensure
1000 Washington Street Suite 710
Boston, MA 02118-6100
Board of Registration of Cosmetology and Barbering
www.mass.gov/dpl/boards
617-727-9940
Demonstrator Application-Fee $136.00
Please attach recent
2” X 2”
passport photograph here
1. Applicant Name:
Last First Middle
2. Maiden Name:
3. Current License#: License Expiration Date:
4. Date of Birth:
5. Permanent Address:
No. Street Apt. #
City/Town State Zip Code
6. Business Address (If Applicable):
No. Street Apt. #
City/Town State Zip Code
7. Contact Phone Number: Cell Phone Number:
E-mail address: _______________________________
8. Social Security Number (Mandatory):____________________________________________
Pursuant to G.L. c. 62C, s. 47A, the Division of Professional Licensure is required to obtain
your social security number and forward it to the Department of Revenue. The Department of
Revenue will use your social security number to ascertain whether you are in compliance with
the tax laws of the Commonwealth.
BOARD USE ONLY
Board:________________
License #:_____________
Type: ________________
Cash #:_______________
Cash Date: ____________
BOARD USE ONLY
Status Code: ______ Issue Date: _________ Lic. Exp. Date: _______
3 of 3 rev. 12/12
9. List any licenses/certifications you hold in the United States or any country or foreign
jurisdiction and the state/jurisdiction from which the license/certification was originally
issued. Please attach a certificate of standing from each state or jurisdiction in which you
are licensed/certified, indicating the status of your license and any relevant disciplinary
information.
10. Has any disciplinary action been taken against you by a licensing/certification board located
in the United States or any country or foreign jurisdiction? Yes: No If yes, a
notarized letter must be submitted with this application. The letter should contain an
explanation and description of incident.
11. Are you the subject of pending disciplinary actions by a licensing/certification board located
in the United States or any country or foreign jurisdiction? Yes: No If yes, a
notarized letter must be submitted with this application. The letter should contain an
explanation and description of incident.
12. Have you ever voluntarily surrendered or resigned a professional license to a
licensing/certification board in the United States or any country or foreign jurisdiction?
Yes: No If yes, a notarized letter must be submitted with this application. The
letter should contain an explanation and description of incident.
13. Have you ever applied for and been denied a professional license in the United States or any
country or foreign jurisdiction? Yes: No If yes, a notarized letter must be
submitted with this application. The letter should contain an explanation and description of
incident.
14. Have you ever been convicted of a felony or misdemeanor in the United States or any
country or foreign jurisdiction, other than a traffic violation for which a fine of less than
$100.00 was assessed? Yes: No If yes, a notarized letter must be submitted with
this application. The letter should contain an explanation and description of incident.
15. Present Employer
16. High School Attended
Name & Address of School
Date Started: Date Finished:
17. Cosmetology School Attended
Name & Address of School
Date Started: Date Finished:
18. I certify, under the pains and penalties of perjury, that I am of good moral character and that
the information I have provided pursuant to this application for licensure is truthful and
accurate. I understand that the failure to provide accurate information may be grounds for
the Massachusetts Board of Registration in Cosmetology to deny me the right to sit as a
candidate or to suspend or revoke a license issued to me in accordance with Massachusetts
Law. I further attest that, pursuant to G.L. c. 62C, s. 49A., to the best of my knowledge and
belief, I have filed all state tax returns and paid all state taxes required by law.
Signature of applicant Date
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
The Division of Professional Licensure by itself and on behalf of boards of registration pursuant to
M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] is registered under the provisions of
M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified
prospective license applicants and current licensees.
As a license applicant or current licensee, I understand that a CORI check will be submitted for my
personal information to the Department of Criminal Justice Information Services (“DCJIS”). I hereby
acknowledge and provide permission to the Division of Professional Licensure to submit a CORI check
for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I
may withdraw this authorization at any time by providing the Division of Professional Licensure written
notice of my intent to withdraw consent to a CORI check.
FOR LICENSING PURPOSES ONLY:
The Division of Professional Licensure may conduct subsequent CORI checks within one year of the
date this Form was signed by me. If subsequent CORI checks are necessary, the Division of
Professional Licensure will provide me with written notice of the subsequent CORI checks.
By signing below, I provide my consent to a CORI check and acknowledge that the information provided
on Page 2 of this Acknowledgement Form is true and accurate.
_________________________________ _________________________________
Signature Date
Please provide the name of the board of registration and license type for which you are applying or currently hold:
_________________________________ _________________________________
Board of Registration License Type
NOTE: DPL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS IT IS
EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL
EMPLOYEE WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE
IDENTIFICATION, OR (2) SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS LIKEWISE
VERIFIED IDENTITY AND THEN MAILED OR OTHERWISE DELIVERED TO THE BOARD'S OFFICES
AT THE ADDRESS SET FORTH ABOVE.
Page 1 of 2
SUBJECT INFORMATION: (An asterisk (*) denotes a required field)
________________________ _________________________ _______________________ ______
*Last Name *First Name Middle Name Suffix
___________________________________________________________________________________
*Maiden Name (or other name(s) by which you have been known)
___________________ ____________________________
*Date of Birth Place of Birth
*Last Six Digits of Your Social Security Number: ______ - _____________
Sex: ______ Height: ____ ft. ____ in. Eye Color: ___________
Driver’s License or ID Number: ___________________ State of Issue: ________________________
Current and Former Addresses:
______ ____________________________________ ______________________ _____ ________
Number Name City/Town State Zip
______ ____________________________________ ______________________ _____ ________
Number Name City/Town State Zip
SECTION A: VERIFICATION BY DPL EMPLOYEE: I hereby certify that I verified the identity of the
above-referenced subject by reviewing the following form(s) of government-issued identification:
1
Passport State-issued driver’s license Military identification State-issued identification card
VERIFIED BY:
Name of Verifying DPL Employee (Please Print)
Signature of Verifying DPL Employee (Please Print) Date
SECTION B: VERIFICATION BY NOTARY:
On this ______ day of _____________, 20____, before me, the undersigned notary public, personally
appeared _________________________________ (name of document signer), and proved to me
through satisfactory evidence of identification, which was the following:
1
Passport State-issued driver’s license Military identification State-issued identification card
to be the person whose name is signed on the preceding or attached document, and acknowledged to
me that (he) (she) signed it voluntarily for its stated purpose.
Notary Public: Notary Commission Expires On:
1
If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by the other
forms of identification documentation as determined by DCJIS. 803 CMR 2.09 (2).
Page 2 of 2
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HD Demonstrator Application

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Completed 3 March 2020

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