Barber -- Out-of-State License Verification

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
VERIFICATION OF HAIRDRESSER / BARBER LICENSURE
TO BE COMPLETED BY APPLICANT

Applicant - Complete the top portion of this form and forward it to each state where you have been licensed, certified or registered as a hairdresser / barber (make copies as necessary).
Last Name
Last Name
First Name
First Name
Middle Name
Middle Name
Maiden Name
Maiden Name
Address

Street Address

City, State, Zip

CityState / Province

Postal / Zip Code
Original License number
(in the state to which the form is being forwarded)
Date Issued

MonthDayYear
I hereby authorize the Authorized Entity * to furnish the Connecticut Department
of Public Health the information requested below.
Signature of Applicant
Enter Full Legal Name
By checking this box I affirm or attest that this is my legal signature.
Date

MonthDayYear
TO BE COMPLETED BY LICENSING AGENCY ONLY
This is to certify that the above named individual was issued license number License number to practice as a hairdresser or barber effective Date .
Basis for licensure in your state:
If licensed by examination, please indicate in what language the exam was administered.
Examination Language
Please indicate the total number of hours of approved education this applicant completed:
Total Number of Hours
Current Status:
Date license expires

MonthDayYear
Has this individual ever been subjected to disciplinary action of any type or is this individual currently the subject of a pending disciplinary action or unresolved complaint?
SEAL
Signed
Enter Full Legal Name
By checking this box I affirm or attest that this is my legal signature.
Title
Title
State
State
Date

MonthDayYear
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
THIS FORM MUST BE SUBMITTED DIRECTLY BY THE LICENSING AGENCY TO:

Hairdresser / Barber Licensure
410 Capitol Ave., MS# 12APP
P.O. Box 340308
Hartford, CT 06134-0308
(860) 509-7603
Should be Empty:

STATE OF CONNECTICUT

VERIFICATION OF HAIRDRESSER / BARBER LICENSURE