Fillable massachusetts COSMETOLOGY BARBERING STUDENT APPRENTICE APPLICATION

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massachusetts COSMETOLOGY BARBERING STUDENT APPRENTICE APPLICATION

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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1
The Commonwealth of Massachusetts
Division of Professional Licensure
1000 Washington Street, Suite 710, Boston, MA 02118
Board of Registration of Cosmetology and Barbering
https://www.mass.gov/orgs/board-of-registration-of-cosmetology-
and-barbering
617-727-9940
COSMETOLOGY & BARBERING STUDENT
APPRENTICE APPLICATION
Your application must include:
o A 2” x 2” photo
o A copy of your driver’s license
o A notarized Criminal Offender Record Information (CORI) Acknowledgment Form.
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
PLEASE NOTE THE FOLLOWING REQUIREMENTS FOR STUDENT
APPRENTICES:
The student must be currently enrolled and in good standing in a Board-approved
Apprentice Program at a licensed Cosmetology or Barbering school
The student cannot also be registered as a shop-employed student
The student must complete 200 school hours before applying to become an
apprentice
The student and the school must obtain a registration for the student as an
apprentice before the student may perform any Cosmetology or Barbering services
in a shop
All shops must be licensed by the Board
All participating students and shops must comply with the Board’s Policy 2019-01:
Student Apprenticeship & Employment
2
The Commonwealth of Massachusetts
Division of Professional Licensure
1000 Washington Street, Suite 710, Boston, MA 02118
Board of Registration of Cosmetology and Barbering
https://www.mass.gov/orgs/board-of-registration-of-cosmetology-
and-barbering
617-727-9940
Cosmetology & Barbering Student Apprentice Application
Please attach recent
2” X 2”
passport photograph here
1. Applicant Name:
Last First Middle
2. Maiden Name:
3. Date of Birth:
4. Permanent Address:
No. Street Apt. #
City/Town State Zip Code
5. Contact Phone Number: Cell Phone Number:
6. E-mail address: ______________________________________________________________
7. 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
Background Questions
1. Has any disciplinary action been taken against you by a licensing board in any
jurisdiction?
Yes: No:
If yes, a notarized letter must be submitted with this application. The letter should contain
an explanation and description of the incident.
2. Do you hold or have you held a professional license in any jurisdiction?
Yes: No:
If your license is with the Board, 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 3-6, if you answer yes, you must submit a notarized letter explaining
the incident.
3. Are you the subject of pending disciplinary action by a licensing board in any jurisdiction?
Yes: No:
4. Have you ever 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 ever been convicted of a felony or misdemeanor in any jurisdiction?
Yes: No:
4
School Information
Name of School __________________________________School License Number __________
School Address _____________
City _______________________________________ State __________ Zip Code ___________
Program Cosmetology Barbering
Student Start Date __________________ Scheduled Completion Date _____________________
Number of School Hours Completed to Date _________________________________________
School Schedule
Days
TUE
WED
THU
FRI
SAT
SUN
Total
Hours
Shop Information
Shop Name ________________________________ Shop License Number _________________
Shop Address __________________
City ____________________________________ State ___________ Zip Code _____________
Shop Owner ___________________________________________________________________
Shop Supervisor __________________________________ License Number ________________
Apprentice Work Schedule:
Days
TUE
WED
THU
FRI
SAT
SUN
Total
Hours
Signature of School Official ____________________________________ Date ______________
5
Certification
I certify, under the pains and penalties of perjury, 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
of Cosmetology and Barbering 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, §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.
____________
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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massachusetts COSMETOLOGY BARBERING STUDENT APPRENTICE APPLICATION

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Completed 7 March 2020

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