Form DBPR COSMO5 "Application for Hair Braiding, Hair Wrapping and Body Wrapping Registration" - Florida

What Is Form DBPR COSMO5?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2015;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DBPR COSMO5 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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1 of 7
State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Application for Hair Braiding, Hair Wrapping and Body Wrapping Registration
Form # DBPR COSMO 5
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Complete all sections of this application.
Pay $25 fee (make check payable to Department of Business and
Hair Braiding
Professional Regulation).
Registration
Submit certificate of completion of the minimum two-day, 16-hour course
requirement.
Complete all sections of this application.
Pay $25 fee (make check payable to Department of Business and
Hair Wrapping
Professional Regulation).
Registration
Submit certificate of completion of the minimum one-day, 6-hour course
requirement.
Complete all sections of this application.
Pay $25 fee (make check payable to Department of Business and
Body Wrapping
Professional Regulation).
Registration
Submit certificate of completion of the minimum two-day, 12-hour course
requirement.
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Hair Braiding, Hair Wrapping or Body Wrapping Registration
a. Applicant must be at least 16 years of age or have received a high school diploma.
b. Applicant must possess a Social Security number to apply.
c. Applicant must complete a board-approved, two-day, 16-hour hair braiding course; a board-
approved, one-day, 6-hour hair wrapping course; or a board-approved, two-day, 12-hour
body wrapping course. A list of board-approved providers is available on the board’s website
at
www.MyFloridaLicense
> Doing Business with us > Cosmetology > Bureau of Education
and Testing > Continuing Education Information. A copy of the course completion certificate
must be submitted with the application.
2. Application Instructions (by section)
a. Section I
i.
Check only one of the application types, and complete Sections II through IV.
b. Section II
i.
Fill out each section completely.
ii.
In the Full Legal Name section, applicants must use the name as it appears on his or her
Social Security card. Do not use nicknames or initials.
iii.
Applicants must furnish their current mailing address.
iv.
Applicant’s addresses are used only for Department purposes and will not be printed on
the license.
v.
If licensed in any other state(s), indicate the other state’s license number, license
effective date, and license expiration date.
vi.
Applicant should list all prior names.
c. Section III (a), (b), and (c)
DBPR COSMO 5 Application for Hair Braiding, Hair Wrapping, and Body Wrapping Registration
Incorporated by Rule: 61-35.011
March, 2015
1 of 7
State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Application for Hair Braiding, Hair Wrapping and Body Wrapping Registration
Form # DBPR COSMO 5
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Complete all sections of this application.
Pay $25 fee (make check payable to Department of Business and
Hair Braiding
Professional Regulation).
Registration
Submit certificate of completion of the minimum two-day, 16-hour course
requirement.
Complete all sections of this application.
Pay $25 fee (make check payable to Department of Business and
Hair Wrapping
Professional Regulation).
Registration
Submit certificate of completion of the minimum one-day, 6-hour course
requirement.
Complete all sections of this application.
Pay $25 fee (make check payable to Department of Business and
Body Wrapping
Professional Regulation).
Registration
Submit certificate of completion of the minimum two-day, 12-hour course
requirement.
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Hair Braiding, Hair Wrapping or Body Wrapping Registration
a. Applicant must be at least 16 years of age or have received a high school diploma.
b. Applicant must possess a Social Security number to apply.
c. Applicant must complete a board-approved, two-day, 16-hour hair braiding course; a board-
approved, one-day, 6-hour hair wrapping course; or a board-approved, two-day, 12-hour
body wrapping course. A list of board-approved providers is available on the board’s website
at
www.MyFloridaLicense
> Doing Business with us > Cosmetology > Bureau of Education
and Testing > Continuing Education Information. A copy of the course completion certificate
must be submitted with the application.
2. Application Instructions (by section)
a. Section I
i.
Check only one of the application types, and complete Sections II through IV.
b. Section II
i.
Fill out each section completely.
ii.
In the Full Legal Name section, applicants must use the name as it appears on his or her
Social Security card. Do not use nicknames or initials.
iii.
Applicants must furnish their current mailing address.
iv.
Applicant’s addresses are used only for Department purposes and will not be printed on
the license.
v.
If licensed in any other state(s), indicate the other state’s license number, license
effective date, and license expiration date.
vi.
Applicant should list all prior names.
c. Section III (a), (b), and (c)
DBPR COSMO 5 Application for Hair Braiding, Hair Wrapping, and Body Wrapping Registration
Incorporated by Rule: 61-35.011
March, 2015
2 of 7
i.
Question 1:
(1)
If you answer “yes” to this question, you must complete Section III (b) [make
additional copies as necessary] of the application and provide a copy of the arrest
report, copies of the disposition or final order(s), and documentation proving all
sanctions have been served and satisfied. You must supply this documentation
for each occurrence. If you are unable to supply this documentation, a certified
statement from the clerk of court for the relevant jurisdiction stating the status of
records is required.
(2)
If you are still on probation, you must supply a letter from your probation officer, on
official letterhead, stating the status of your probation.
ii.
Question 2:
(1)
If you answer “yes” to this question, you must complete Section III (b) [make
additional copies as necessary] of the application and provide a copy of the judgment
or decree. You must also supply documentation proving all sanctions have been
served and satisfied, or if not, stating the current status of any proceedings.
iii.
Question 3:
(1)
If you answer “yes” to this question, you must complete Section III (c) [make
additional copies as necessary] of the application and supply copies of
documentation explaining the denial or pending action.
iv.
Question 4:
(1)
If you answer “yes” to this question, you must complete Section III (c) [make
additional copies as necessary] of the application and supply copies of the order(s)
showing the disciplinary action taken against the license, or documentation showing
the status of the pending action.
d. Section IV
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
3. Other Information
a. Course providers should supply a course completion certificate to all students upon
completion of the course.
b. Employment Eligibility
i.
Applicants may begin working after the submission of a complete application to the
Department of Business and Professional Regulation, including a copy of their course
completion certificate, payment of required fees, and upon notification that their
application is complete. Applicants may work in a licensed salon pending receipt of their
registration or until they receive notification that their application is incomplete so long as
the salon owner or their representative is provided with a copy of the applicant’s
completed registration application.
ii.
Please see
Florida Board of Cosmetology FAQs
for additional information.
c. Post-Licensure Procedures
i.
All Hair Braiders, Hair Wrappers, and Body Wrappers must renew his or her registration
on or before October 31 of every other year, according to the fee schedule as outlined in
Rule 61G5-24.008, Florida Administrative Code.
ii.
Prior to the expiration of each licensure period, all registrants shall complete a board-
approved HIV/AIDS training course for renewal.
DBPR COSMO 5 Application for Hair Braiding, Hair Wrapping, and Body Wrapping Registration
Incorporated by Rule: 61-35.011
March, 2015
3 of 7
State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Application for Hair Braiding, Hair Wrapping, and Body Wrapping Registration
Form # DBPR COSMO 5
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
For additional information see the Instructions at the beginning of this application.
Section I – Application Type
CHECK ONE OF THE APPLICATION TYPES
 Hair Braiding Registration
 Hair Wrapping Registration
 Body Wrapping Registration
[0506/1030]
[0505/1030]
[0504/1030]
Section II – Applicant Information
APPLICANT INFORMATION
Social Security Number*
FULL LEGAL NAME
Last/Surname
First
Middle
Suffix
Birth Date (MM/DD/YYYY)
Gender
/
/
 Male  Female
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
Primary Phone Number
Primary E-Mail Address
RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number
Fax Number
Alternate E-Mail Address
* The disclosure of your Social Security number is mandatory on all professional and occupational license applications, is solicited
by the authority granted by 42 U.S.C. §§ 653 and 654, and will be used by the Department of Business and Professional Regulation
pursuant to §§ 409.2577, 409.2598, 455.203(9), and 559.79(3), Florida Statutes, for the efficient screening of applicants and
licensees by a Title IV-D child support agency to assure compliance with child support obligations. It is also required by § 559.79(1),
Florida Statutes, for determining eligibility for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be
used by the Department of Business and Professional Regulation to identify licensees for tax administration purposes.
DBPR COSMO 5 Application for Hair Braiding, Hair Wrapping, and Body Wrapping Registration
Incorporated by Rule: 61-35.011
March, 2015
4 of 7
Section II – Applicant Information – continued
CURRENT/PRIOR LICENSE INFORMATION
If you currently hold or have previously held a business or professional license/registration in Florida or
elsewhere, please list each one below (attach additional copies of this page as necessary):
Date (From)
Date (To)
1. License/Registration Type
State
/
/
/
/
License Number
Name Used
Date (From)
Date (To)
2. License/Registration Type
State
/
/
/
/
License Number
Name Used
Date (From)
Date (To)
3. License/Registration Type
State
/
/
/
/
License Number
Name Used
PRIOR NAME INFORMATION
Have you used, been known as, or are currently known by another name (e.g., maiden name or
nickname) or alias other than the name signed to the application? 
Yes
No
If your answer is yes, state name or names used below:
Last/Surname
First
Middle
Suffix
Last/Surname
First
Middle
Suffix
Last/Surname
First
Middle
Suffix
Section III (a) – Background Questions
BACKGROUND QUESTIONS
1.
 Yes
 No
Have you ever been convicted or found guilty of, or entered a plea of nolo
(If yes, please
contendere or guilty to, regardless of adjudication, a crime in any
complete
jurisdiction, or are you currently under criminal investigation? This
Section III (b))
question applies to any criminal violation of the laws of any municipality,
county, state or nation, including felony, misdemeanor and traffic offenses
(but not parking, speeding, inspection, or traffic signal violations), without
regard to whether you were placed on probation, had adjudication
withheld, were paroled, or pardoned. If you intend to answer “NO”
because you believe those records have been expunged or sealed by
court order pursuant to Section 943.0585 or 943.059, Florida Statutes, or
applicable law of another state, you are responsible for verifying the
expungement or sealing prior to answering "NO." YOUR ANSWER TO
THIS QUESTION MAY BE CHECKED AGAINST LOCAL, STATE AND
FEDERAL RECORDS. FAILURE TO ANSWER THIS QUESTION
ACCURATELY MAY RESULT IN THE DENIAL OR REVOCATION OF
YOUR LICENSE. IF YOU DO NOT FULLY UNDERSTAND THIS
QUESTION, CONSULT WITH AN ATTORNEY OR CONTACT THE
DEPARTMENT.
2.
 Yes
 No
Has any judgment or decree of a court been entered against you in this or
(If yes, please
any other state, province, district, territory, possession or nation, related
complete
to the practice or profession for which you are applying, or is there any
Section III (b))
such case or investigation pending?
3.
 Yes
 No
Have you ever had an application for registration, certification, or
(If yes, please
licensure in Florida or in any other jurisdiction denied, or is there now
complete
pending a proceeding or investigation to deny such an application?
Section III (c))
DBPR COSMO 5 Application for Hair Braiding, Hair Wrapping, and Body Wrapping Registration
Incorporated by Rule: 61-35.011
March, 2015
5 of 7
Section III (a) – Background Questions – continued
4.
 Yes
 No
Has any license, registration, or permit to practice any regulated
(If yes, please
profession, occupation, vocation, or business been revoked, annulled,
complete
suspended, relinquished, surrendered, or otherwise disciplined in Florida
Section III (c))
or in any other jurisdiction, or is any such proceeding or investigation now
pending?
If you answered “YES” to any question in questions 1-4 above, please refer to Section 2(c) of Instructions
for detailed instructions for providing complete explanations, including requirements for submitting
supporting legal documents. Please complete Section III (b) for your response to questions 1 and 2, and
complete Section III (c) for your response to questions 3 and 4. If you have more than three offenses to
document in Section III (b), or more than one offense to document in Section III(c), attach additional
pages as necessary.
Section III (b) – Explanation(s) for Background Questions 1 and 2
EXPLANATION
Offense
County
State
Penalty/Disposition
Date of Offense (MM/DD/YYYY)
Have all sanctions been satisfied?
/
/
 Yes  No
Description
EXPLANATION
Offense
County
State
Penalty/Disposition
Date of Offense (MM/DD/YYYY)
Have all sanctions been satisfied?
/
/
 Yes  No
Description
DBPR COSMO 5 Application for Hair Braiding, Hair Wrapping, and Body Wrapping Registration
Incorporated by Rule: 61-35.011
March, 2015