%86,1(66 &21680(5 6(59,&(6 $1'+286,1*$*(1& ﾱ Governor Edmund G. Brown Jr
BOARD OF BARBERING AND COSMETOLOGY
P.O. Box 944226, Sacramento, CA 94244-2260
P (800) 952-5210 F (916) 575-7281 www.barbercosmo.ca.gov
OUT-OF-STATE APPLICANT
AFFIDAVIT OF EXPERIENCE ﾱ FORM C
Instructions to the Applicant:
Provide this form to a disinterested individual who can verify your experience. A disinterested individual can be an employer, employee, or client who can attest to your licensed experience. The individual muｖｗ＃ｆｒｐｓｏｈｗｈ＃ｗｋｈ＃ｓｒｕｗｌｒｑ＃ｐｄｕｎｈｇ＃ﾳＷｒ＃Ｅｈ＃Ｆｒｐｓｏｈｗｈｇ＃ｅ｜＃ Ｇｌｖｌｑｗｈｕｈｖｗｈｇ＃Ｌｑｇｌｙｌｇｘｄｏ＃Ｒｑｏ｜１ﾴ＃＃Ｒｑｆｈ＃ｆｒｐｓｏｈｗｈｇ／＃ｖｘｅｐｌｗ＃ｗｋｌｖ＃ｉｒｕｐ＃ｄｏｒｑｊ＃ｚｌｗｋ＃｜ｒｘｕ＃Ｄｓｓｏｌｆｄｗｌｒｑ＃ｉｒｕ＃Ｈ｛ｄｐｌｑｄｗｌｒｑ／＃ｗｋｈ＃ｄｓｓｕｒｓｕｌｄｗe fee,
and other applicable documents to the Board. Only licensed work experience will be considered.
SECTION A: APPLICANT INFORMATION
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Social Security Number |
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Date of Birth |
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SECTION B: TO BE COMPLETED BY A DISINTERESTED INDIVIDUAL ONLY |
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The Applicant listed above has performed the following type of work at the specified location during the time period indicated below.
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Type of work (check all boxes that are applicable):
Cosmetology |
Barbering |
Electrology |
Skin Care |
Nail Care |
Time Period
From: Month _____________ Year ____________ To: Month_______________ Year_____________
SECTION C: DISINTERESTED INDIVIDUAL AND APPLICANT CERTIFICATION
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
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Signature of Disinterested Individual |
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Signature of Applicant |
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Form F-03E-145 |
Page 1 of 2 |
Revised 1/08 |
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%86 ,1(6 6 &216 80(5 6 (59,&(6 $1'+286 ,1*$*(1& – Governor Edmund G. Brown Jr.
BOARD OF BARBERING AND COSMETOLOGY
P.O. Box 944226, Sacramento, CA 94244-2260
P (800) 952-5210 F (916) 575-7281 www.barbercosmo.ca.gov
INFORMATION COLLECTION, ACCESS AND DISCLOSURE
The Information Practices Act, Sec. 1798.17 Civil Code, requires the following information to be provided when collecting information from individuals.
AGENCY NAME
Board of Barbering and Cosmetology
TITLE OF OFFICIAL RESPONSIBLE FOR INFORMATION MAINTENANCE
Executive Officer
ADDRESS
2420 Del Paso Road, Suite 100, Sacramento, CA 95834
INTERNET ADDRESS
www.barbercosmo.ca.gov
TELEPHONE AND FAX NUMBERS
(916) 574-7570 phone (916) 575-7281
AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE INFORMATION
Sections 7300 to 7457, inclusive, comprising Chapter 10 Division 3, of the California Business and Professions Code.
CONSEQUENCES OF NOT PROVIDING ALL OR ANY PART OF THE REQUESTED INFORMATION: It is mandatory that you provide all information requested. Omission of any item of requested information will result in the application being rejected as incomplete.
PRINCIPAL PURPOSE(S) FOR WHICH THE INFORMATION IS TO BE USED
The information requested will be used to determine qualifications for licensure or certification to determine compliance with the group and corporate practice provisions of the law and to establish positive identification.
ANY KNOWN OR FORESEEABLE DISCLOSURES WHICH MAY BE MADE OF THE INFORMATION Your completed application becomes the property of the board and will be used by authorized personnel to determine your eligibility for a license or certification. Information on your application may be transferred to other governmental or law enforcement agencies. Pursuant to the California Public Records Act (Gov. Code Section 6250 et seq.) and the Information Practices Act (Civ. Code Section 1798.61), the names and addresses of persons possessing a license or registration may be disclosed by the department unless otherwise specifically exempt from disclosure under the law.
Consequently, the personal name and address information entered on the attached form(s) may become public information subject to disclosure.
SOCIAL SECURITY NUMBER (SSN) DISCLOSURE
Disclosure of your social security number is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 [42 U.S.C.A. Section 405(c)(2)(C)] authorize collection of your social security number. Your social security number will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order for family support in accordance with section 17520 of the Family Code, or for verification of licensure or examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security number, you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you.
AB 1424
Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board may share taxpayer information with the board. You are obligated to pay your state tax obligation and your license may be suspended if the state tax obligation is not paid.
Revised December 2011
