COSMETOLOGY TEACHER REGISTRATION APPLICATION

Transcription

1 Oregon COSMETOLOGY TEACHER REGISTRATION APPLICATION Complete the following information and ATTACH copies of certificates or licenses that are legally required for employment in the field in which you teach (i.e., hair design, nail technology, etc.). Teachers must hold all Oregon licenses, and successfully pass qualifying exams legally required for employment in the field in which they teach Oregon Administrative Rule (OAR) (3). Applicants must: Have graduated from high school as evidenced by a photocopy of a transcript indicating graduation, diploma, or its foreign equivalent. As an alternative, evidence of obtaining a General Education Development (GED) certificate. Be at least 18 years of age as evidenced by a photocopy of a birth certificate, driver s license, or baptismal certificate. Hold all Oregon licenses, certificates, and ratings legally required for employment in the field in which they teach. And meet one of the following requirements: 1) Have a combination of no less than two years education and work experience in the subject applicant will be teaching: Minimum of one-year work experience as a certified practitioner following State Board certification or licensure is required. OAR (21)(A). Additional work experience may be required to meet the two-year minimum should the educational component be less than one year. OR 2) Completion of the 1000-hour teacher-training course at an approved school of hair design (school must submit a copy of student's transcript). The Executive Director shall approve teacher-training programs of 200 hours for a teacher who s certification has lapsed more than three (3) years or if the teacher is coming from another state whose licensing requirements are less than the minimum requirements for Oregon. OAR (24)(c). Work experience must have been within the last five years. Part-time experience will be allowed if the total hours equal the equivalent of required work experience. 1,875 hours per year is considered full-time. The following must be submitted before an application will be reviewed. (OAR (21)) Completed application; Copy of current Oregon practitioner s certificate(s), issued from OR Health Licensing Agency; Copy of high school diploma, transcript, or GED certificate; Cosmetology Teacher Registration Form (Rev 8/2013)

2 Copy of birth certificate, baptismal certificate, or driver s license to verify age; Copy of 1000-hour teacher-training course transcript (if applicable); and $50.00 Application Fee. Make checks payable to the Higher Education Coordinating Commission. Send application to: Private Career Schools Licensing Unit Cosmetology Teacher Registration Form (Rev 8/2013)

3 Oregon TEACHER REGISTRATION FORM FOR SCHOOLS OF BARBER, HAIR DESIGN, ESTHETICS AND NAIL TECHNOLOGY *All boxes must be completed for your application for registration to be reviewed.* Please print clearly. Applicant Name Date of Birth **Social Security # Address Home Phone (include area code) Home Address Alternate Phone (include area code) City State Zip Code + 4 Education/Training History Instructors must have a High School Diploma, GED, or postsecondary degree or certification. High School Diploma: Yes No GED: Yes No Attach copies. Cosmetology School(s) Attended Name of Institution Dates of Attendance Number of hours completed Cosmetology Licenses Held Please include a copy of all your licenses with application License Type License No. Expiration Date

4 Work Experience Work experience must have been within the last five years. Indicate if work experience is full-time or part-time. State the number of hours worked per month. You must have at least two years of education and work experience in the subject applicant will be teaching and hold appropriate licenses/certificates in the subject that they instruct. Part-time experience will be allowed if the total hours equal the equivalent of two years of full-time work experience. Full-time work experience is a minimum of 1,875 hours per year (37.5 hours per week times 50 week). OAR (3). Employer Name, Address, and Phone Number Dates of Employment Full-time or if Part-time # hrs- wk/mo Supervisor and Detailed Description of Duties Performed **Attach separate sheet, if more space is needed** Other Post-Secondary Work (Summer Schools, extension courses, seminars, any military experience, etc.) School you plan on working for (if known): Criminal History Have you ever been convicted of a crime other than a minor traffic violation? Yes No If yes, attach a separate sheet with an employer recommendation, copy of the disposition letter, or reports from a probation officer, etc. [OAR (12)] By my signature below I hereby certify that the information submitted on or relating to this form is true and correct and grant the PCS Licensing Unit permission to check civil or criminal records to verify any statement made on this application. The PCS Licensing Unit may revoke any license upon evidence that the applicant knowingly made any false statements in the application for this license. I understand that providing incomplete or inaccurate information WILL result in a delay of my application and may result in disciplinary action by the PCS Licensing Unit. Signature of Applicant Date Note: This form must be filed and processed with the prior to the commencement of any instruction except in utilizing emergency provisions. OAR (4). In emergency situations, not to exceed three months, schools may hire substitute teachers who are the bestqualified persons available. Under no circumstances shall students be allowed to substitute as approved teachers.

5 **Social Security Number Requirement Authority, and Disclosure Statement As part of your application as a teacher, director, or agent for a licensed private career school, as issued by the, you are required to provide your Social Security Number (SSN) to the Commission as part of the application process. This is a mandatory requirement, as authorized by state and federal law. Oregon Revised Statutes (ORS) and 42 USC 666(a)(13). Your SSN will be stored in the Commission s electronic database using the highest level of encrypted security protocols. It will be provided on a quarterly basis to the Oregon Department of Justice through secured electronic means for the purpose of enforcing child support orders. Your SSN will not be printed or displayed in any public forum through any medium unless expressly required by state or federal law. Failure to provide your SSN will be a basis for the to refuse to issue or renew a license or registration as described above. Any other use or disclosure of your SSN will require your written authorization.