Fillable Mobile Individual Registration Form (Commonwealth of Massachusetts)

Fill Online, Printable, Fillable, Blank Mobile Individual Registration Form (Commonwealth of Massachusetts) Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Mobile Individual Registration Form (Commonwealth of Massachusetts)

On average this form takes 10 minutes to complete

The Mobile Individual Registration Form (Commonwealth of Massachusetts) form is 5 pages long and contains:

  • 0 signatures
  • 8 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
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
BOARD USE ONLY Please attach recent
Board:________________
License #:_____________ 2” X 2”
Type: ________________
Cash #:_______________ passport photograph here
Cash Date: ____________
Individual Licensee Registration to Provide Mobile Services
The Board’s mobile cosmetology and barbering policy allows mobile services at locations chosen by the
client, such as a client’s home, office, etc., and services in a mobile vehicle equipped as a shop. Under this
policy, “all persons and businesses that offer Mobile Services shall register.” This means that each of the
following must be registered and approved before offering mobile services: (1) a licensee offering mobile
services, whether on location or in a vehicle (an individual); (2) a business with more than one licensee
providing mobile services (a mobile business); and (3) a vehicle equipped as a shop (a mobile unit). Each
licensee, business, and unit must register using a different form. An owner of a business or unit does not
need to be a licensee, but all individuals who provide mobile services must be licensed to provide those
services. This is a registration form ONLY for an individual licensee who will be offering mobile
services.
To be complete, this application must include: (1) a passport photograph; (2) a copy of your driver’s license or
state identification card; (3) a copy of your professional license(s); and (4) a signed Criminal Offender Record
Information (CORI) form, a copy of which is attached.
After the Board receives and approves your registration, you will receive an approval letter. You are
not authorized to provide mobile services until you receive that approval letter.
Applicant Information
Name: _______________ _______ ________ __________
Last First Middle
Telephone Number: _______________________________ Email Address: ___________________________
Social Security or Federal Tax Identification Number: ________________________________________
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.
License Type(s):
Type 1 Cosmetologist Type 3 Manicurist Type 6 Aesthetician Master Barber
Type 2 Operator Type 7 Aesthetician Apprentice Barber
License Number(s): _____________________________________________________________________
2
Permanent Street Address in Massachusetts (Not a P.O. Box) Where Records Will Be Maintained:
_______________________________________
Street Address
____________________________________________________________________________________________
City State Zip
Background Questions
1. Do you hold or have you held a professional license in any jurisdiction? Yes: No:
If your license is with the Board of Cosmetology and Barbering, please list your license number:
_________________________________________________________________________________________
For other licenses, please contact the jurisdiction’s licensing authority and arrange for that authority to send a
certificate of standing directly to the Board indicating the status of your license, information on any pending
actions, and any disciplinary information.
For questions 2-6, if your answer is yes, please state details on the line provided. (Use a separate sheet if
necessary.)
2. Has any disciplinary action been taken against you by a licensing board in any jurisdiction?
Yes: No:
_________________________________________________________________________________________
3. Are you the subject of pending disciplinary action by a licensing board in any jurisdiction?
Yes: No:
__________________________________________________________________________________________
4. Have you voluntarily surrendered a professional license to a licensing board in any jurisdiction?
Yes: No:
__________________________________________________________________________________________
5. Have you ever applied for and been denied a professional license in any jurisdiction?
Yes: No:
__________________________________________________________________________________________
6. Have you been convicted of a felony or misdemeanor in any jurisdiction?
Yes: No:
_______________________________________________________________________________________
3
Attestation
I certify, under the pains and penalties of perjury, that the information I have provided pursuant to this application
for registration is truthful and accurate. I understand that the failure to provide accurate information may be
grounds for the Massachusetts Board of Registration of Cosmetology and Barbering to suspend or revoke a
license or registration issued to me in accordance with Massachusetts Law. I further attest that, pursuant to
Massachusetts General Laws c. 62C, §49A, to the best of my knowledge and belief, I and/or the business entity I
represent have filed all state tax returns and paid all state taxes required by law. I further agree that I will adhere
to all applicable Massachusetts laws and regulations pertaining to the practice of cosmetology or barbering.
Name and Signature:
______________ _________
Signature of Applicant Print Name 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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Mobile Individual Registration Form (Commonwealth of Massachusetts)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document