Fillable Photo #1 Photo #2 Application for Licensure by (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Photo #1 Photo #2 Application for Licensure by (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 Licensure by Endorsement
Check all that apply: Cosmetologist-Hairstylist Manicurist
Skin Care Specialist Barber Beautician
Date : ____________________________
A nonrefundable application ling fee of $100.00 plus a licensing fee of $90 during the rst year of a licensing cycle, or $45
during the second year of a licensing cycle, 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 examination/licensure 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 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
Photo #1
Attach two clear, full-face pass-
port-style photographs (2˝x
2˝) of your head and shoul-
ders, taken within the past six
months.
Two photos are required with
each application.
Staple one photo here and one
in the square to the right.
Photo #2
Please provide a copy of your birth certicate, passport or valid
New Jersey driver’s license with this application.
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will 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.
5. Student Loan
Are you in default in regard to any student loan obligation(s)? Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued
your student loan, for the eventual repayment of the loan. You will not be able to obtain a license unless you provide the
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 arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? 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(1) through d will result in a 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.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
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
Noof guilty, non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes
9. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea
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? NoYes
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
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate
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 limited 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 and Training
N.J.A.C. 13:28-1.1(e)3 states:
“Applicants who have obtained training in another state or country shall demonstrate, by way of
certication from the licensing authority in the state or country that such training is substantially
equivalent to the training offered at cosmetology and hairstyling schools licensed in New Jersey.
Applicants holding a license from another state or country who have engaged in the practice
of cosmetology and hairstyling, beauty culture, barbering, skin care specialty, or manicuring
for at least three years in that state or country, may submit, in lieu of the documentation of
training required in this paragraph, a notarized afdavit of work experience and a letter of
certication of licensure from the licensing authority in that state or country.”
1. What is the name and address of the high school you attended? _________________________________________________
Name of high school
_______________________________________________________________________________________________________
Street address City State ZIP code
2. How many years of high school have you completed? ______________
3. Have you graduated from high school? Yes No
If “Yes,” what was or will be the date of your graduation? ___________________
Month Year
Please provide a copy of your high school diploma or certied high school transcript with this application.
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. Please provide a copy of your G.E.D. certicate with this application.
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
___________________________________
Date certicate was issued
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. (Attach additional sheets of paper to this application if necessary.)
_______________________________________________________________________________________________________
Name of school
_______________________________________________________________________________________________________
Street address City State ZIP code
Dates attended: From ________________ To _________________
Did you graduate? Yes No No. hours completed ___________________
Experience
Applicants need only list the work experience they’ve acquired in the elds of cosmetology/hairstyling, beauty culture, barbering,
manicuring or skin care specialty.
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: _________________________ (include area code) Hours per week: ____________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Employed from ____________________________ to _____________________________
Month Year Month Year
Immediate supervisor’s name: _____________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: _________________________ (include area code) Hours per week: ____________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Employed from ____________________________ to _____________________________
Month Year Month Year
Immediate supervisor’s name: _____________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: _________________________ (include area code) Hours per week: ____________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Employed from ____________________________ to _____________________________
Month Year Month Year
Immediate supervisor’s name: _____________________________________________________________________________
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: __________________________________________________
County of:________________________________________________
I, _______________________________________________________ , in making this application to the New Jersey State Board of
Cosmetology and Hairstyling for licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey
and the Rules of the New Jersey State Board of Cosmetology and Hairstyling, swear (or afrm) that I am the applicant and that
all 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 licensure or certication or to
withhold renewal of or suspend or revoke a license or certicate issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:5B-1 et seq., together with the Rules and Regulations of the New Jersey
State Board of Cosmetology and Hairstyling, N.J.A.C. 13:28-1.1 et seq., and fully understand that in receiving licensure or
certication from the Board, I bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities
for the purpose of verifying my qualications for licensure or certication. 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.
_________________________________________________
Signature of applicant
Sworn and subscribed to before me this _________
day of __________________________ , _________
Month Year
___________________________________________
Name of Notary Public (please print)
___________________________________________
Signature of Notary Public
} ss.
Afx seal here
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Cosmetology and Hairstyling
124 Halsey Street, 6th oor, P.O. Box 45003
Newark, New Jersey 07101
(973) 504-6400
Certicate of Experience
from your Present or Former Employer
I hereby certify that ____________________________________________________________________ has been employed as
First name Middle initial Last name
__________________________________________________ in the ___________________________________________________
Fill-in classication Name of shop
shop, located at ______________________________________________________________________________________________
Street address City State ZIP code
for the period from __________________________ to _________________________ covering _____ years and _____ months.
I believe him/her to be qualied under the New Jersey Cosmetology and Hairstyling Law (N.J.S.A. 45:5B-1 et seq.) to take an
examination for a license. I am making this certication with the full knowledge that the New Jersey State Board of Cosmetology
and Hairstyling relies on this certication to grant the applicant the privilege of examination.
__________________________________________
Employer’s name (please print)
_______________________________ __________________________________________
Date Employer’s signature
(Must be notarized)
Sworn and subscribed to before me this ___________
day of _________________________ , ____________
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
Afx
seal here
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Cosmetology and Hairstyling
124 Halsey Street, 6th oor, P.O. Box 45003
Newark, New Jersey 07101
(973) 504-6400
Verication of State License
Note: This form is to be completed by the licensing authority in the state where you received your original
license and returned from the licensing authority directly to the address stated above.
A separate form must be used for each state. This form may be reproduced.
Name of applicant: ___________________________________________________________________________________
Last name First name Middle initial
The above-named applicant is a licensee of the State of ____________________________________ and was
issued a license number _______________________________ on __________________________________________.
Month Day Year
The applicant was licensed by the following:
Examination: __________________________________________________________________
Endorsement/Reciprocity from the State of: _________________________________________
Other: _________________________________________________________________________
The license status is:
Current and in good standing expiring on: __________________________________________
Revoked or suspended: __________________________________________________________
Inactive/expired on: _____________________________________________________________
Other: (please attach explanation)
The licensee does does not have a record of disciplinary history with this agency. (Attach disciplinary
information, if applicable.)
I hereby certify that to the best of my knowledge and belief, the foregoing is a true statement of the record of the individual
on this form.
_____________________________________________________
Name of Board
_____________________________________________________
Name of person completing this form (please print)
_____________________________________________________
Title
_____________________________________________________
Signature
_____________________________________________________
Date
Afx
Board Seal
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
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Photo 1 Photo 2 Application for Licensure by (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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