Form Si-59 - Application For Student Instructor Permit printable pdf download

IDAHO STATE BOARD OF COSMETOLOGY

Bureau of Occupational Licenses

1109 Main Street, Suite 220

Boise, Idaho 83702-5642

(208) 334-3233

hpiippo@ibol.state.id.us

APPLICATION FOR STUDENT INSTRUCTOR PERMIT

Complete this form by providing (please print) the requested information and submit it to the address noted above. The

signatures of the applicant and school agent must be notarized and the fee ($25.00) must be attached. Returned checks are

subject to a $20.00 collection fee.

I wish to be registered as a student instructor of: (please check one)

[ ]Cosmetology

[ ]Electrology

[ ]Cosmetology

[ ]Electrology

in the state of Idaho under provisions of Title 54, Chapter 8, Idaho Code as amended.

1. Full Name (Mr., Mrs., or Ms.) ____________________________________________________________________

2. Mailing address________________________________________________________________________________

Street

City

State

Zip

3. Date of Birth _____-_____-______

License number ____________

month day

year

4. Social Security No. ______-____-______ Home phone number (____)____________ E-mail _________________

5. Name of Cosmetology School attending ______________________________________________________________

6. Have you ever been convicted of any State or Federal felony?

[ ]Yes

[ ]No

(If yes, please attach a detailed statement, including a summary of the charges, the final order, any probation or parole documentation,

and any other relevant information.)

7. Do you have practical experience under licensure?

[ ]Yes

[ ]No

(If yes, please attach a detailed statement of your experience, noting the names and addresses of the businesses in which you gained

your experience and the dates of experience for each business listed.)

AFFIDAVIT

I hereby certify that I am the person named above and that I have no infectious or contagious disease which may pose a

threat to the general public and that I am of good moral character and temperate habits. I swear or affirm that the

information provided on and attached to this application is true and accurate to the best of my knowledge and belief.

I hereby authorize and direct any person, agency, firm, or other entity to release to the Bureau of Occupational Licenses or

it’s identified agent any and all information, communications recommendations, reports, records, statements, or

disclosures, whether public, privileged or confidential, that may relate to my professional qualifications or credentials or

that may have bearing on my eligibility for licensure.

_____________________________________________________

Signature of applicant

State of ______________, County of _________________, ss.

Subscribed and sworn before me this ______ day of _______________________, 20 _____.

________________________________________________________________

(seal)

Notary Public official signature

residing at________________________________________________________

my commission expires_____________________________________________

(page 1 of 2)

SI-59-revised 08/00

Form Si-59 - Application For Student Instructor Permit

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