DLR COSMETOLOGY APPLICATION FOR EXAMINATION IN SOUTH DAKOTA Rev. 01/2020
SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
SOUTH DAKOTA COSMETOLOGY COMMISSION
500 E Capitol Ave, Pierre, SD 57501
Tel: 605.773.6193 Fax: 605.773.7175 cosmetology.sd.gov
APPLICATION FOR EXAMINATION IN SOUTH DAKOTA
PRINT CLEARLY. All areas must be completed. The correct examination fee by either check or money order must be
attached. If applying for a temporary license a $6 fee must also be attached.
PERSONAL INFORMATION
Name: _____________________________________________________________ Date of Birth: ___________________
Address: __________________________________________ ____________________________ _____ __________
STREET CITY STATE ZIP
Tel
: ______________________________ SD Student License Number: ______________________________________
Email address (if you have o
ne):________________________________________________________________
Indicate your language preference for the written theory & South Dakota laws examination:
☐ English ☐ Vietnamese
Do you need reasonable testing accommodations due to a disability?
☐ Yes ☐ No
Have you ever been convicted of, plead guilty or nolo contendere to a felony or any state or federal crime relating to
narcotic drugs?
☐ Yes ☐ No If yes, explain on a separate sheet giving date, place and full particulars and attach as
part of this application.
EDUCATION INFORMATION
School:________________________________________________ City:__________________________ State:_____*
Date completed:____________________ Total clock hours of education:___________
I authorize the Cosmetology Commission to release the results of my State Board Examinations to the above-named
school:
☐ Yes ☐ No
*If this is an out-of-state school, you must get a certification from that state’s Cosmetology Board. You must also submit a copy of
birth certificate, copy of high school diploma or GED, Social Security Number and a current photograph.
I hereby make application for the state board examinations to be conducted by the Cosmetology Commission. I declare and
affirm under the penalties of perjury that this information has been examined by me, and to the best of my knowledge and
belief is, in all things, true and correct. If granted a temporary license to practice in South Dakota, I promise to abide by all the
laws of the state of South Dakota governing these practices.
Signature of Applicant:________________________________________________ Date: __________________________
APPLICATION FOR TEMPORARY SOUTH DAKOTA LICENSE*
Salon Name:_______________________________________________________ Tel: ____________________________________
Salon Address/City:__________________________________________________________________________________________
Owner Name:__________________________________________ Estimated starting date of employment: __________________
*NOTE: All areas must be completed before the license will be issued. Temporary license fee is $6. A temporary license will be issued only when the applicant makes
application for a temporary license before taking the examination and has secured employment in a salon licensed by the Commission. This temporary license shall
be valid until the examination results are received and is not renewable. If the examinations are failed, the temporary license becomes invalid immediately.
Examination Categories and Fees (check only one box) Non-refundable ($106 total if applying for temporary license)
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