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
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 .
EndorsementExamination
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
ActiveInactiveLapsed
Date license expires

MonthDayYear
YesNo
SEAL
Signed
Enter Full Legal Name
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