ࡱ> %` bjbj a̟̟)444$X@'@'@'P'l(X@$L),",,,2/r0P1X???????$AhOD@u4O5/"2/O5O5@,,}@K7K7K7O58,4,?K7O5?K7K794.:,@) Y@'59=D@0@:,ES6E.:E4.:p1r2K73tv3111@@6j111@O5O5O5O5XXX<XXX<XXX Oregon Health Licensing Agency - Cosmetology  700 Summer St. NE, Suite 320 Salem, OR 97301-1287 Phone: (503) 378-8667 Fax: (503) 370-9004 Website:  HYPERLINK "http://WWW.OREGON.GOV/OHLA" www.oregon.gov/ohla Email: info.ohla@state.or.us INDEPENDENT CONTRACTOR APPLICATION COMPLETE ALL PARTS OF THIS FORM. PLEASE TYPE OR PRINT IN BLACK OR BLUE INK. 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. 1. Applicant InformationAPPLICANT NAME LAST FIRST MIDDLE INTIAL  FORMTEXT        FORMTEXT        FORMTEXT  MAILING ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT      BUSINESS TELEPHONE (  FORMTEXT     )  FORMTEXT       FORMTEXT       HOME TELEPHONE (  FORMTEXT     )  FORMTEXT       FORMTEXT      E-MAIL  FORMTEXT      BIRTHDATE (MO/DAY/YR)  FORMTEXT    /  FORMTEXT    /  FORMTEXT     SOCIAL SECURITY NUMBER (REQUIRED)  FORMTEXT       FORMTEXT      FORMTEXT    NAME of FACILITY (Where you work)  FORMTEXT      FACILITY TELEPHONE NUMBER  FORMTEXT       FORMTEXT FACILITY LICENSE NUMBER  FORMTEXT      FACILITY ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT      Please document your practitioner certification number(s) and expiration date(s) below.CERTIFICATION #EXPIRATION DATE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      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 in 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.  Signature of Applicant: Date: FORMTEXT       Do not write in this section  Official use only New Independent Contractor#: COS-IC- Transaction #: Transaction Amount $ Initials OTC  FORMCHECKBOX  Verified ID  FORMCHECKBOX  Method of Payment:  FORMCHECKBOX Cash ,-./LMbhyz캬ydyLd9dy$hm/hcF0JCJOJQJ^JaJ/jhm/hcFCJOJQJU^JaJ)jhm/hcFCJOJQJU^JaJ hm/hcFCJOJQJ^JaJ h}Q)hcFCJOJQJ^JaJ hGmhcFCJOJQJ^JaJhcFCJOJQJ^JaJ@jhGmhcF5B*CJOJQJU^JaJmHnHphu hcF56CJOJQJ^JaJ&h{ hcF56CJOJQJ^JaJ-Lby  o$ $ $0$&`#$-D/IfM ]0gdWo $0x$&`#$/If]0gdWogdcF  0^0gdcF  0^0gdcF$ !0^0a$gdcF !$0/)fS]0^/gdcF     3 p w   ˷vdVEV hJhcFCJ OJQJ^JaJ hcFCJ OJQJ^JaJ #hODhcF5CJOJQJ^JaJ hcAhcFCJOJQJ^JaJ hVohcFCJOJQJ^JaJ h^RhcFCJOJQJ^JaJhcFCJOJQJ^JaJ&hOhcF56CJOJQJ^JaJ hcF56CJ OJQJ^JaJ &h}Q)hcF56CJ OJQJ^JaJ hcF5CJOJQJ^JaJ  {c $$&`#$/IfgdWokd$$Ifl+t+  t 6` 0t+44 lap ytWo k $$&`#$/IfgdWo}kd$$Ifli+t+ t 6`0t+2H2 s44 laytWo V {`G  #$&`#$/IfgdWo  #$&`#$/IfgdWokd0$$Iflh+t+  t 6` 0t+44 lap ytWo    $ & 4 6 8 L N T X v x z ߯ߗudL/jhRDhcFCJOJQJU^JaJ hm/hcFCJOJQJ^JaJ hJhcFCJ OJQJ^JaJ h vhcFCJOJQJ^JaJ/jh vhcFCJOJQJU^JaJ/j]h vhcFCJOJQJU^JaJ/jh vhcFCJOJQJU^JaJhcFCJOJQJ^JaJ#jhcFCJOJQJU^JaJV X x iP  #$&`#$/IfgdWo  #$&`#$/IfgdWo{kdM$$Ifl^+t+ t 6`0t+44 lap ytWo Ŵ֕}ִhW?h/jhThcFCJOJQJU^JaJ hThcFCJOJQJ^JaJ)jhThcFCJOJQJU^JaJ/j hRDhcFCJOJQJU^JaJhcFCJOJQJ^JaJ h7hcFCJ OJQJ^JaJ hJhcFCJ OJQJ^JaJ hRDhcFCJOJQJ^JaJ#jhcFCJOJQJU^JaJ.jhcFCJOJQJU^JaJmHnHu   8 iiWiWi  #$IfgdWo  #$&`#$/IfgdWo{kdh$$Ifl^+t+ t 6`0t+44 lap ytWo      & ( * 4 6 8 : ` b f h | пНпwfWCW&jhcF5CJOJQJU^JaJhcF5CJOJQJ^JaJ h[{hcFCJOJQJ^JaJhcFCJ OJQJ^JaJ /jhThcFCJOJQJU^JaJ hThcFCJOJQJ^JaJ h7hcFCJ OJQJ^JaJ hJhcFCJ OJQJ^JaJ )jhThcFCJOJQJU^JaJ4jhThcFCJOJQJU^JaJmHnHu8 : ` b T7 I4$&`#$/IfgdWo I4$&`#$/IfgdWokds$$Ifl^Fp"+  t 6`0t+    44 lapytWo| ~ éÏ~pbTC hG3JhcFCJOJQJ^JaJhcFCJOJQJ^JaJhcFCJ OJQJ^JaJ hcFCJOJQJ^JaJ hThcFCJOJQJ^JaJ2jF hThcF5CJOJQJU^JaJ2jhThcF5CJOJQJU^JaJhcF5CJOJQJ^JaJ&jhcF5CJOJQJU^JaJ2jVhThcF5CJOJQJU^JaJb z| I4$IfgdWo X#$&`#$/IfgdWo I4$&`#$/IfgdWo$&,.BDFLNTVjlnvxz|~ҹҪҪҹҪҪvҹҪeTFhcFCJ OJQJ^JaJ hThcFCJOJQJ^JaJ hG3JhcFCJ OJQJ^JaJ 2j hG3JhcF5CJOJQJU^JaJ2j( hG3JhcF5CJOJQJU^JaJhcF5CJOJQJ^JaJ1jhcF5CJOJQJU^JaJmHnHu&jhcF5CJOJQJU^JaJ2j hG3JhcF5CJOJQJU^JaJ|~lQQ6QQ p#$&`#$/IfgdWo  #$&`#$/IfgdWokd $$Ifl%0+{ t 6`0t+44 lapytWoraSA#jhcFCJOJQJU^JaJhcFCJ OJQJ^JaJ hJhcFCJ OJQJ^JaJ hhcFCJOJQJ^JaJ.jhcFCJOJQJU^JaJmHnHu/j hmhcFCJOJQJU^JaJhcFCJOJQJ^JaJ#jhcFCJOJQJU^JaJ h~Z|hcFCJOJQJ^JaJhcFCJOJQJ^JaJhcFCJOJQJ^JaJ 246:<JL`bdlnսկrY?Y2j' hhcF5CJOJQJU^JaJ1jhcF5CJOJQJU^JaJmHnHu2j hhcF5CJOJQJU^JaJ&jhcF5CJOJQJU^JaJhcF5CJOJQJ^JaJhcFCJOJQJ^JaJ.jhcFCJOJQJU^JaJmHnHu#jhcFCJOJQJU^JaJ/j7 hewhcFCJOJQJU^JaJp:  #$&`#$/IfgdWo  #$IfgdWo oy#F$&`#$/If]FgdWonp˹~l~Tl*CJOJQJ^JaJ hm[hcFCJOJQJ^JaJhcFCJOJQJ^JaJ/jhZhcFCJOJQJU^JaJhcFCJOJQJ^JaJ hwhcFCJOJQJ^JaJ.jhcFCJOJQJU^JaJmHnHu#jhcFCJOJQJU^JaJ/jhZhcFCJOJQJU^JaJ!lK!$ l dT!$&`#$/Ifa$gdWokdb$$Ifl0+n t 6`0t+44 lapytWo!"#,-jjL l dT!$&`#$/IfgdWo $H$&`#$/If^HgdWo{kd+$$Ifls+t+ t 6`0t+44 lap ytWo-./vr`S@ b &$If]gdWo &]gdcF &]`gdcF $00]0^0gdcF{kd$$Ifl+t+ t 6`0t+44 lap ytWo./EFGKLMWX  tͻޭ|`O>,#h[hcF5CJOJQJ^JaJ h[hcFCJOJQJ^JaJ hcF5>*CJOJQJ^JaJ7jhUC)hcF>*CJOJQJU^JaJmHnHu2jqhUC)hcF>*CJOJQJU^JaJ,jhUC)hcF>*CJOJQJU^JaJhcFCJOJQJ^JaJ#hUC)hcF>*CJOJQJ^JaJ h-hcFCJOJQJ^JaJ#h-hcF5CJOJQJ^JaJhcF>*CJOJQJ^JaJtvx$&.0LϾωwcwcwcT@T&jhcF5CJOJQJU^JaJhcF5CJOJQJ^JaJ&h[hcF5>*CJOJQJ^JaJ#h[hcF5CJOJQJ^JaJ#h$HhcF5CJ OJQJ^JaJ hcF>*CJOJQJ^JaJ&hIhcF5>*CJOJQJ^JaJ hcF5>*CJOJQJ^JaJ#h$HhcF5CJOJQJ^JaJhcF5CJ OJQJ^JaJ hcF5CJOJQJ^JaJvxLwNwAlkd $$$Ifl{&}+ t0}+644 laytWo &$If]gdWo  $If]gdWo :$If]gdWo  $If]gdWoLNPnpé×qZq@+)jh[hcFCJOJQJU^JaJ2j h[hcF5CJOJQJU^JaJ,jh[hcF5CJOJQJU^JaJ#h[hcF5CJOJQJ^JaJ&h[hcF5>*CJOJQJ^JaJ#hG3JhcF5CJOJQJ^JaJ2j] hG3JhcF5CJOJQJU^JaJhcF5CJOJQJ^JaJ&jhcF5CJOJQJU^JaJ2jhG3JhcF5CJOJQJU^JaJ FORMCHECKBOX Discover  FORMCHECKBOX Visa  FORMCHECKBOX Master Card  FORMCHECKBOX Check  FORMCHECKBOX Money Order  FORMCHECKBOX Purchase Order Independent Contractor Registration Check List NOTE: The independent contractor registration issued by the Oregon Health Licensing Agency, by itself, does not exempt you from Employment Department Law. To be excluded from unemployment coverage a worker must meet all the requirements of ORS 657.040. This license alone does not prove the independent contractor meets, or will continue to meet, these requirements. This is a reminder to both the facility owners and the independent contractors. Both parties are responsible for complying with the requirements of ORS 657.040 and ORS 670.600. If you fail to do so, the facility owner may be liable for unemployment taxes on that worker as an employee. For further information, please contact the Employment Department Tax Office in your area or call (503) 947-1488. Requirements below need to be met to successfully complete this application.  FORMCHECKBOX  I currently hold a valid Oregon Cosmetology Practitioner s Certification in at least one of the following fields practice:  FORMCHECKBOX Barbering  FORMCHECKBOX Hair Design  FORMCHECKBOX Esthetics  FORMCHECKBOX Nail Technology  FORMCHECKBOX  Application Fees and Registration Fees are included with this application.  FORMCHECKBOX  Application Fee = $15.00  FORMCHECKBOX  Registration Fee= +$50.00 Total Fees = $65.00  FORMCHECKBOX  Application is completed, signed, and dated.      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