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Applicant Information

First name*

Last name*

Address*

Phone*

Email*

Date of Birth*

Month

Day

Year

Barbering Qualifications

Current Barber License Number*

Issuing State*

Issue Date*

Month

Day

Year

Expiration Date*

Month

Day

Year

Years of Experience as a Licensed Barber*

Attach Proof of Employment or Affidavit from Employer(s)

Education and Training

Name of Barber School*

Address*

Dates Attended

To*

From*

Total Hours Completed*

Certificate/Diploma Received?*

Yes

No

Attach Copy if Applicable

Attach Copy of Certificate/Diploma*

Apprenticeship (If Applicable)

Supervisor Name

License Number

Dates of Apprenticeship

To

From

Total Hours

Examination and Certification

Have you passed the Master Barber Examination?*

Yes

No

Attach Proof*

Professional Conduct

Have you ever had a barbering license revoked or suspended?*

Yes

No

(If Yes, explain)

Are there any pending complaints or investigations against you with any barbering board?*

Yes

No

If Yes, explain

Attachments

* Proof of identity (e.g., driver’s license, passport)

Applicant Declaration

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that falsification of any information may result in denial of this application or revocation of my license.

Signature*

Date*

Designed by LIONZ DEN, INC.

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