Form DBPR COSMO4-A "Application for Registration by Endorsement" - Florida

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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 June 1, 2016;
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State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Application for Registration by Endorsement
Form # DBPR COSMO 4-A
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Complete this application.
Nail Specialist or
Pay $59 fee (make check payable to Department of Business and
Facial Specialist or
Professional Regulation).
Full Specialist by
Submit a certification of licensure from state where applicant holds a
Endorsement
current and active specialist license/registration. Certification must verify
a current and active license and the number of educational hours
completed.
Submit certificate of completion from a board-approved Initial HIV/AIDS
course.
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 Specialty 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:
i.
Hold a current and active license or registration in another state whose requirements are
substantially similar to, equivalent to, or greater than the qualifications required of
applicants from Florida.
ii.
Provide certification of licensure from state where applicant holds a current and active
specialist license/registration. Certification must verify a current and active license and
the number of educational hours completed.
d. Applicant must submit a course completion certificate from a board-approved Initial HIV/AIDS
course provider with their application. The board-approved Initial HIV/AIDS course must
have been completed within two years of submitting an application, and the course must be
at least 4 hours long. Refer to the list of board-approved
Initial HIV/AIDS
Courses.
2. Application Instructions (by section)
a. Section I
i.
Check only one of the application types.
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.
c. Section III
i.
If applying for registration by endorsement, which means that the applicant holds a
current and active license or registration in another state whose requirements are equal
to or more stringent than Florida requirements, applicant must submit a certification of
licensure with their application. If applying for registration by endorsement, which
means that the applicant holds a current and active license or registration in
DBPR COSMO 4-A Registration by Endorsement
Incorporated by Rule: 61-35.011
2016 June
1 of 7
State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Application for Registration by Endorsement
Form # DBPR COSMO 4-A
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Complete this application.
Nail Specialist or
Pay $59 fee (make check payable to Department of Business and
Facial Specialist or
Professional Regulation).
Full Specialist by
Submit a certification of licensure from state where applicant holds a
Endorsement
current and active specialist license/registration. Certification must verify
a current and active license and the number of educational hours
completed.
Submit certificate of completion from a board-approved Initial HIV/AIDS
course.
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 Specialty 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:
i.
Hold a current and active license or registration in another state whose requirements are
substantially similar to, equivalent to, or greater than the qualifications required of
applicants from Florida.
ii.
Provide certification of licensure from state where applicant holds a current and active
specialist license/registration. Certification must verify a current and active license and
the number of educational hours completed.
d. Applicant must submit a course completion certificate from a board-approved Initial HIV/AIDS
course provider with their application. The board-approved Initial HIV/AIDS course must
have been completed within two years of submitting an application, and the course must be
at least 4 hours long. Refer to the list of board-approved
Initial HIV/AIDS
Courses.
2. Application Instructions (by section)
a. Section I
i.
Check only one of the application types.
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.
c. Section III
i.
If applying for registration by endorsement, which means that the applicant holds a
current and active license or registration in another state whose requirements are equal
to or more stringent than Florida requirements, applicant must submit a certification of
licensure with their application. If applying for registration by endorsement, which
means that the applicant holds a current and active license or registration in
DBPR COSMO 4-A Registration by Endorsement
Incorporated by Rule: 61-35.011
2016 June
2 of 7
another state whose requirements are equal to or more stringent than Florida
requirements. Applicant must only submit a license certification from the state
where applicant holds a current and active license/registration, so long as the
certification verifies the number of educational hours completed.
(1)
Applicants for registration by endorsement for Nail Specialist must have completed at
least 240 hours of training prior to being registered as a specialist.
(2)
Applicants for registration by endorsement for Facial Specialist must have completed
at least 260 hours of training prior to being registered as a specialist.
(3)
Applicants for registration by endorsement for Full Specialist must have completed at
least 500 hours of training prior to being registered as a specialist. Full Specialists
must have completed 240 hours of nail specialty training and 260 hours of facial
specialty training, for a total of 500 hours or more of training.
ii.
Indicate the states in which the applicant has held licenses.
iii.
Applicant must take a board-approved Initial HIV/AIDS course and submit a certificate of
completion along with the application. Refer to the list of board-approved
Initial HIV/AIDS
Courses.
d. Section IV (a), (b), and (c)
i.
Question 1:
(1)
If you answer “yes” to this question, you must complete Section IV (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 IV (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 IV (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 IV (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.
e. Section V
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. Post-Registration Procedures
i.
A Cosmetologist, Facial Specialist, Nail Specialist and Full Specialist must renew his or
her license 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 licensed Cosmetologists, Facial
Specialists, Nail Specialists and Full Specialists shall complete a minimum of 16 hours of
continuing education. Please see Rule 61G5-32.001, Florida Administrative Code, for
details concerning what subjects areas must be completed for continuing education
credit.
DBPR COSMO 4-A Registration by Endorsement
Incorporated by Rule: 61-35.011
2016 June
3 of 7
State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Application for Registration by Endorsement
Form # DBPR COSMO 4-A
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
 Nail Specialist Registration by Endorsement [0507/1032]
 Facial Specialist Registration by Endorsement [0508/1032]
 Full Specialist Registration by Endorsement [0509/1032]
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 4-A Registration by Endorsement
Incorporated by Rule: 61-35.011
2016 June
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 – Specialty Registration by Endorsement
SPECIALTY REGISTRATION BY ENDORSEMENT
NOTE: To be eligible for specialty registration by endorsement, out-of-state applicants must hold
a current and active license to practice a cosmetology specialty, and applicants for:
1. Nail Specialist must have completed 240 hours or more of training;
2. Facial Specialist must have completed 260 hours or more of training;
3. Full Specialist must have completed 240 hours of nail specialty training and 260 hours of
facial specialty training, for a total of 500 hours or more of training.
List any states in which you are currently or were previously licensed:
1.
2.
3.
DBPR COSMO 4-A Registration by Endorsement
Incorporated by Rule: 61-35.011
2016 June
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Section IV (a) – Background Questions
BACKGROUND QUESTIONS
 Yes
 No
1.
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 IV(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.
 Yes
 No
2.
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 IV(b))
such case or investigation pending?
 Yes
 No
3.
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 IV(c))
 Yes
 No
4.
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 IV(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 instructions for providing complete explanations, including requirements for submitting supporting legal
documents. Please complete Section IV (b) for your response to questions 1 and 2, and complete
Section IV (c) for your response to questions 3 and 4. If you have more than two offenses to document in
Section IV (b), or more than one offense to document in Section IV (c), attach additional pages as
necessary.
Section IV (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
DBPR COSMO 4-A Registration by Endorsement
Incorporated by Rule: 61-35.011
2016 June