LICENSURE BY EXAMINATION APPLICATION

LICENSURE BY EXAMINATION APPLICATION SEND APPLICATION TO: PSI/Colorado Barber Cosmetology Program PO Box 887 Wheat Ridge, CO 80034 EXAMINATION Please select practical skills examination(s) that you are applying for. COSMETOLOGIST MANICURIST ESTHETICIAN HAIR STYLIST BARBER CANDIDATE LICENSURE HISTORY Choose one application type that best describes your license history and provide the required information for that application type. First License: Candidate has never been licensed in the state of Colorado as a barber, cosmetologist, esthetician, hairstylist, or manicurist. Have you ever worked in the state of Colorado as a barber, cosmetologist, esthetician, hairstylist, or manicurist? NO YES (If Yes, you must submit the Information Regarding Work History form located at www.psiexams.com.) Endorsement: Candidate has received endorsement approval letter from DORA. Reinstatement: Candidate was previously licensed and is applying for reinstatement of that license. My previous license number is: (You must include an Authorization To Test letter issued by the Office of Barber and Cosmetology Licensure.) License Type Addition: Applicant is currently or was previously licensed and is applying for a different license type. My previous license type is: Barber Cosmetologist Esthetician Hairstylist Manicurist REQUIRED FEE All candidates are required to apply for examination by submitting the Licensure by Examination Application, along with the application fee. Within 48 business hours of the application received date, you will be notified, via email, that your application has been approved or that your application is deficient (specifying the outstanding requirements). Payment is accepted by company check, money order or cashiers check made payable to PSI. Personal checks are not accepted. Examination Approval Candidate (Candidates who have not previously tested or whose application has expired) APPLICATION FEE...$28.00 Written Candidate (Candidates who have passed the Practical Exam and are applying for the Written Exam.) APPLICATION FEE...$28.00 Please note that all fees are nontransferable and nonrefundable. If you miss your examination, you are still responsible for the fee and must submit it with the application. CANDIDATE INFORMATION A. NAME LEGAL LAST NAME LEGAL FIRST NAME SUFFIX MIDDLE INITIAL MAIDEN NAME OTHER LAST NAME B. SOCIAL SECURITY NUMBER

Candidates who do not have a social security number are eligible for licensure only if the applicant is a foreign resident who was NOT trained in the United States and is NOT physically present in the United States. Otherwise the application will be deemed incomplete. These applicants must include with this application the Social Security Number Affidavit form which can be obtained at www.psiexams.com. Check here if you do not have a social security number, are a foreign resident trained outside of the U.S., are not physically present in the U.S., and have included the Social Security Number Affidavit form. C. DATE OF BIRTH MM DD YEAR D. EMAIL ADDRESS @ E. CONTACT INFORMATION NUMBER STREET APARTMENT NUMBER CITY STATE ZIP CODE Disclosure of Addresses. Consistent with Colorado law, all addresses on record with the Department of Regulatory Agencies, Division of Professions and Occupations are public record and must be provided to the public when requested. It is your responsibility to keep your address and contact information up-to-date. All letters, renewal notices, and licenses are mailed to the last known address of record. If your address is not current, it is possible you will not receive important documents. CELL OR HOME PHONE WORK PHONE SCREENING QUESTIONS Prior to answering these questions, please review the Criminal Disclosure Letter which is attached to this application. If you answer Yes to one or more of the screening questions below, you are required to provide the documentation as indicated. 1. Have you ever been convicted of, pled guilty or nolo contendere to, or accepted deferred judgment or prosecution to a felony? NO YES (If Yes, include with this application original documentation with a court seal and the Information Regarding Felony Conviction form.) 2. Are you are currently incarcerated, on parole, on probation, or on court supervision as a result of a felony? NO YES (If Yes, include with this application original documentation with a court seal and page 2 of the Information Regarding Felony Conviction form titled Monitoring Information from Court or Probation/Parole Officer.) 3. SUBSTANCE ABUSE: Do you now abuse or excessively use, or have you in the last five years abused or excessively used, any habit forming drug, including alcohol, or any controlled substance that has a) resulted in any accusation or discipline for misconduct, unreliability, neglect of work, or failure to meet professional responsibilities; or b) affected your ability to practice as a [insert profession here: ] safely and competently? NO YES (If Yes, include with this application the Information Regarding Addiction Status form.) All applicants must provide their original Record of Completion at the time of application. A blank Record of Completion form can be obtained at www.psiexams.com. If you did not complete your training in Colorado, enter the name of the school and the state where the school is located. Attach the original school record. Copies are not accepted. OUT-OF-STATE SCHOOL NAME: STATE: CANDIDATE SIGNATURE This application is valid for one year from the date it is received by PSI. If your application is incomplete and the related documents are not provided, your application and related documents will be destroyed and your fees will be forfeited. You will be required to apply as a new applicant and provide new documentation and fees. Please be advised that in Colorado, supplying false information when applying for licensure is punishable by law. I state, under penalty of perjury in the second degree, as defined in 18-8-503, Colorado Revised Statutes, that the information contained in this application is true and correct to the best of my knowledge. In accordance with 18-8-01(2) (a) (1), Colorado Revised Statutes, false statements made herein are punishable by law and may constitute violation of the practice act. CANDIDATE SIGNATURE DATE

IMPORTANT INFORMATION WHEN SENDING THE APPLICATION TO PSI SEND APPLICATION TO: PSI/Colorado Barber Cosmetology Program PO Box 887 Wheat Ridge, CO 80034 The approval of your application may be delayed if you do not provide a complete application to PSI. Please complete the Application Checklist to ensure that your application is complete. All sections of this application have been completed and my original signature has been provided. My social security number has been provided or the Social Security Number Affidavit is included with this application. An original Record of Completion or original out-of-state school records are included with this application. A completed Affidavit of Eligibility is included with this application. The required fee of $28 is attached and is made payable to PSI. Other The Information Regarding Work History form is included with this application as required for first time licensees who have previously worked in Colorado. The Authorization to Test Letter is attached as required for candidate s endorsement or reinstatement. The following Screening question documentation for a Yes answer to questions in Section 4 is included or not required: Original court stamped documentation of criminal convictions for Questions #1 and #2. The Information Regarding Felony Conviction form for Question #1. The Monitoring Information from Court or Probation/Parole Officer form for Question #2. The Information Regarding Addiction Status form for Questions #3 and #4. ADDITIONAL INFORMATION Mandatory Practice Act. Colorado has a mandatory practice act, which means that you may not practice as a Barber, Cosmetologist, Esthetician, Hairstylist, or Manicurist in this state without a Colorado license. Submission of this application does not guarantee licensure. Therefore, do not make life or career decisions based on the probability that you may receive a license. Plan ahead for the time it will take for us to receive all required documents and complete our evaluation and the required examinations. Basic Requirements. Requirements for examination are outlined in the Barber and Cosmetologist Act, specifically Section 12-8-114; and the of the Colorado Office of Barber and Cosmetology Licensure, specifically Rule 7. Both documents can be found online at www.dora.colorado.gov/professions/cosmetology. LICENSE EXPIRATION INFORMATION Barber, Esthetician, Hairstylist, and Manicurist licenses expire on March 31 of even-numbered years and must be renewed to continue practicing. All new applicants who are issued a license within 120 days of the upcoming renewal expiration date will be issued a license with the subsequent expiration date. For example, licenses issued between December 1, 2013 and November 30, 2015 will expire March 31, 2016. Licenses issued after November 30, 2015 will expire March 31 2018. Cosmetologist licenses expire on April 30 of either odd-numbered years or even-numbered years, are dependent upon the issuance date, and must be renewed to continue practicing. All new applicants who are issued a license within 120 days of the upcoming renewal expiration date will be issued a license with the subsequent expiration date. For example, licenses issued between January 1, 2014 and December 31, 2014 will expire April 30, 2016. Licenses issued between January 1, 2015 and December 31 2015 will expire April 30 2017.

PSI/Colorado Barber Cosmetology Program PO Box 887 Wheat Ridge, CO 80034 LICENSEE/APPLICANT FULL LEGAL NAME Last First Middle Suffix Colorado Professional or Occupational License/Certification/Registration Number: (if already licensed) Professional or Occupational License/Certification/Registration type applying for: AFFIDAVIT OF ELIGIBILITY Pursuant to H.B. 06S-1009, C.R.S. 24-34-107, ALL applicants for original licensure* or licensees renewing or reinstating a current Colorado license after January 1, 2007 are required to complete and sign this Affidavit of Eligibility. *The word "licensure" is used as a general term. While most of the professions and occupations are licensed, others may be certified, registered, or listed. For precise terminology and requirements related to a profession or occupation, please consult the website of the appropriate board or program. Section A: LAWFUL PRESENCE in the United States Section A: LAWFUL PRESENCE in the United States I am a U.S. citizen. Check one of the acceptable secure and verifiable documents in Section B that applies and fully complete the information requested. Complete documentation must be provided upon request. I am not a U.S. citizen, but I am lawfully present in the U.S. and authorized by the Department of Homeland Security to be employed in the U.S. Check one of the acceptable secure and verifiable documents in Section B that applies and fully complete the information requested. Complete documentation must be provided upon request. I am not physically present in the U.S. under 8 U.S.C. sec. 1621 (c)(2)(c) or employed in the U.S. pursuant to 8 U.S.C. sec. 1621 (c)(2)(a). Check one option, a or b below, then skip to Section C. (Do not complete Section B.) I am a U.S. citizen, not physically present or employed in the United States. I am a Foreign National, not physically present or employed in the United States. Government Issued Identification Driver s license or permit Government issued ID card Valid U.S. military ID/common access card Colorado Department of Corrections inmate ID Tribal ID card Section B: SECURE AND VERIFIABLE DOCUMENTS Select ONE document in this section if you checked 1 or 2 in Section A Name of state agency Full name as shown on driver s or federal agency that license or state/federal issued ID issued the document License/ID Number Expiration Date U.S. passport Certificate of Naturalization

Government Issued Identification Certificate of U.S.) Citizenship Valid Temporary Resident card Valid I-94 issued by Canadian government Valid I-94 with refugee/asylum stamp Section B: SECURE AND VERIFIABLE DOCUMENTS (continued) Name of state agency Full name as shown on driver s or federal agency that license or state/federal issued ID issued the document License/ID Number Expiration Date Valid I-766 (Employment Authorization Card) Issuing Federal Agency: Name on card Alien Number (A#) Card Number Valid from Expires Valid I-551 (Resident Alien or Permanent Resident Card) Issuing Federal Agency: Name on card Alien Number (A#) Country of Birth Card Expires Resident Since Valid foreign passport with an unexpired visa with proper classification for work authorization and an unexpired I-94 Issuing Foreign Country Passport Number Visa Number Visa Class (ex.: J-1, P-1, H-1B, etc.) Date of Entry Until Date Valid foreign passport bearing an unexpired Processed for I-551 stamp or with an attached unexpired Temporary I-551 visa Issuing Foreign Country: Passport Number: Section C: ATTESTATION I understand that this sworn statement is required by law because I have applied for or hold a professional or commercial license regulated by 8 U.S.C. sec. 1621. I understand that state law requires me to provide proof that I am lawfully present in the United States when asked as well as submission of a secure and verifiable document. I may also be required to provide proof of lawful presence. I understand that in accordance with sections 18-8-503 and 18-8-501(2)(a)(I), C.R.S., false statements made herein are punishable by law. I state under penalty of perjury in the second degree, as defined in 18-8-503, C.R.S. that the above statements are true and correct. I am the person identified above and the information contained herein is true and correct to the best of my knowledge. I understand that under Colorado law, providing false information is grounds for denial, suspension or revocation of a license, certificate, registration or permit. I understand that the above information must be disclosed to the Department of Regulatory Agencies upon request and is subject to verification. Print Full Legal Name Signature (Full Name) Date

Lauren Larson Director, Division of Professions and Occupations IMPORTANT NOTICE TO: FROM: SUBJECT: All Applicants Director of the Division of Professions and Occupations Licensure and Criminal History Thank you for your interest in becoming a licensed* professional within the Division of Professions and Occupations. Before you submit your application, please be aware of a few facts regarding criminal conduct, convictions, and disciplinary actions in other states. The mission of the Division of Professions and Occupations is public protection through effective licensure and enforcement. One way the Division safeguards consumers is by issuing licenses to fully qualified, competent, and ethical applicants. During the licensing process and depending on the specific application the Division may ask whether you have ever been disciplined in any state, arrested, charged, convicted, or pled guilty to a crime. An arrest, subsequent criminal conviction, or disciplinary action is not an automatic disqualification from licensure. Rather, the appropriate board or program will look at the facts surrounding the criminal conduct and disciplinary action in addressing your license application. You should know that licensure is a privilege, not a right. One thing you must do to obtain the privilege is to be complete and accurate in disclosing information on your application. Be sure to list all relevant complaints, disciplinary actions, arrests, charges, or convictions in response to the appropriate licensure questions. Failure to fully and accurately disclose requested criminal history information, alone, could constitute grounds for denial of your application or revocation of your license. When requested, you must include information regarding prior conduct. This remains the case when the conduct is seemingly unrelated to the activities of a profession, and when the conduct involves deferred sentences or judgments. Remember, even following licensure, you are still required to notify your professional licensing board or program about subsequent convictions and disciplinary actions in other states. Please be aware that the Division conducts audits of its licensing database against several criminal and national disciplinary databases. This allows the Division to verify the truthfulness of your application and track subsequent criminal and disciplinary conduct after initial licensure. Keep in mind, your license will not necessarily be revoked, or your application denied, if you have been disciplined, arrested, charged or convicted. But, you will most likely be denied or revoked if you fail to disclose requested information. *The word "license" is used as a general term. While most of the professions and occupations are licensed, others may be registered, certified, or listed. For precise terminology and requirements related to a profession or occupation, please consult the website of the appropriate board or program. 1560 Broadway, Suite 1350 Denver, Colorado 80202 Phone 303.894.7800 Fax 303.894.7693 www.dora.state.co.us V/TDD 711