ࡱ>   %` bjbj .̟̟d $---PQRH`-616161613B[67GGGGGGG$JhLG0<2"30<0<G6161]H>>>0<vR6161G>0<G>>@b"BA61S bn~-<vA:EdsH0HA,M=MBAMBA8k9>9l]:888GG=j888H0<0<0<0<d   Oregon Health Licensing Agency - Cosmetology  700 Summer St. NE, Suite 320 Salem, OR 97301-1287 Phone: (503) 378-8667 Fax: (503) 370-9004 Website: http://www.oregon.gov/ohla E-mail: info.ohla@state.or.us PRACTITIONER QUALIFICATION / EXAMINATION APPLICATION Please check which examinations(s) you are applying for: Barbering  FORMCHECKBOX  Hair Design  FORMCHECKBOX  Esthetics  FORMCHECKBOX  Nail Technology  FORMCHECKBOX  Oregon Laws & Rules  FORMCHECKBOX 1. Applicant InformationAPPLICANT NAME LAST FIRST MIDDLE INTIAL  FORMTEXT        FORMTEXT        FORMTEXT  RESIDENTIAL ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT      MAILING ADDRESS (IF DIFFERENT FROM RESIDENTIAL ADDRESS)  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT       TELEPHONE (  FORMTEXT     )  FORMTEXT       FORMTEXT       E-MAIL  FORMTEXT       GENDER  FORMCHECKBOX  Female  FORMCHECKBOX  MaleBIRTHDATE (MO/DAY/YR)  FORMTEXT    /  FORMTEXT    /  FORMTEXT      SOCIAL SECURITY NUMBER ( REQUIRED )  FORMTEXT       FORMTEXT      FORMTEXT      Have you ever been known under any other name?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If yes, list full name(s):  FORMTEXT       Do you hold or have you previously held licensure, certification or registration with the Oregon Health Licensing Agency? If yes, please document your license / certification / registration number and expiration date below.LICENSE / CERTIFICATION / REGISTRATION #EXPIRATION DATE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      2. Individual Records Questions Are you now, or have you ever been, the subject of any active or inactive disciplinary action or voluntary resignation of a certificate, license, permit or registration imposed by any licensing or regulatory authority in this or any other state? (Disciplinary action includes, but is not limited to, probation, civil penalties, limiting in any way, of a license, certificate, registration or permit.)  FORMCHECKBOX  NO  FORMCHECKBOX  YES If yes, please explain. (Attach additional pages if needed.)  FORMTEXT       Have you ever been convicted of a felony?  FORMCHECKBOX  NO  FORMCHECKBOX  YES If yes, please explain. (Attach additional pages if needed.)  FORMTEXT        Complete the reverse side of this application ( Do not write in this section Official use only Transaction #: Transaction Amount $ Initials  FORMCHECKBOX  OTC Verified ID FORMCHECKBOX  Method of Payment:  FORMCHECKBOX Cash  FORMCHECKBOX Discover  FORMCHECKBOX Visa  FORMCHECKBOX Master Card  FORMCHECKBOX Check  FORMCHECKBOX Money Order  FORMCHECKBOX Purchase Order  As part of your application for initial or renewed occupational, professional or recreational license, certification, or registration issued by the Health Licensing Agency, you are required to provide your Social Security Number to the Health Licensing Agency. This is mandatory. The authority for this requirement is ORS 25.785, ORS 305.385, 42 USC 405(c)(2)(C)(i), and 42 USC 666(a)(13). Failure to provide your Social Security Number will be a basis to refuse to issue or renew the license, certification, or registration you seek. This record of your Social Security Number is used for child support enforcement and tax administration purposes (including identification) only, unless you authorize other uses of the number. Although a number other than your Social Security Number appears on the face of the licenses, certificates, or registrations issued by the Health Licensing Agency, your Social Security Number will remain on file with the Health Licensing Agency. I have examined this application and certify that it is true, correct, and complete. I understand that knowingly making a false statement on this application will be cause for denial, suspension, or revocation of registration. I have enclosed the required fees and documentation. I understand my application may be subject to a criminal background check. I authorize the use of my Social Security number for that purpose. If registered to practice in Oregon, I will comply with the laws and rules adopted by the Agency. ALL PARTS OF THIS FORM MUST BE COMPLETE BEFORE SIGNING. Call the Oregon Health Licensing Agency (OHLA) if you have any questions. Incomplete applications will be returned. Use N/A to indicate information that is not applicable. This information will be used by OHLA to conduct a criminal history check, a background investigation, and to document your qualifications.  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 R&,+0]0^`gdaJ $0x]0gdS; $0x]0^gd3 $0x]0^gd\1tkd($$Ifl*+ t 6@0+644 layt2B#######$!"#WXfôxcR:cRcR/j)hhGZ|CJOJQJU^JaJ hhGZ|CJOJQJ^JaJ)jhhGZ|CJOJQJU^JaJ hGZ|hlCJOJQJ^JaJUhGZ|hGZ|56>*CJ aJ haJhaJ56>*haJ>*CJOJQJ^JaJh>*CJOJQJ^JaJh>*CJOJQJ^JaJ&jhxN>*CJOJQJU^JaJ1jhxN>*CJOJQJU^JaJmHnHu##VWu•z (`gd (gd7 `gd (`gd `gd `gd (`gd (gdGZ| $$`$a$gdaJ $$`$a$gd) ATION CHECK LIST  FORMCHECKBOX  Application fee - $15 for each field of practice  FORMCHECKBOX  Examination fee(s) - $25 for each examination  FORMCHECKBOX  Verification of a current: Drivers license, State ID card, Passport or Military ID card  FORMCHECKBOX  TRANSCRIPT (Official transcript must be received directly from an Oregon Licensed Career School; Transcript will be filed with the Oregon Health Licensing Agency.)  FORMCHECKBOX  Application is completed, signed, and dated Affirmative Action Voluntary Question The State of Oregon has an Affirmative Action Policy. If you choose to provide this information, it will help us evaluate the effectiveness of our affirmative action programs. This will also be used for research and statistical purposes.  Ethnic Background (check only one)  FORMCHECKBOX  (A) Asian or Pacific Islander: Persons having origins in any of the peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa.  FORMCHECKBOX  (B) African American (not of Hispanic origin): Persons having origins in any of the black ethnic groups.  FORMCHECKBOX  (H) Hispanic: Persons having origins in any of the Mexican, Puerto Rican, Cuban, Central or South American or other Spanish cultures, regardless of ethnicity.  FORMCHECKBOX  (I) Native American or Alaskan Native: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.  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