"Education Certification Course Provider Application" - South Dakota

Education Certification Course Provider Application is a legal document that was released by the South Dakota Department of Labor & Regulation - a government authority operating within South Dakota.

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  • Released on August 1, 2018;
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SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
SOUTH DAKOTA COSMETOLOGY COMMISSION
500 E Capitol Ave, Pierre, SD 57501
Tel: 605.773.6193
Fax: 605.773.7175
cosmetology.sd.gov
EDUCATION CERTIFICATION COURSE PROVIDER APPLICATION
APPLICATION FEE: $100
(Non-refundable)
Check or money order payable to: Cosmetology Commission
GENERAL PROVIDER INFORMATION
Provider’s Name: _________________________________________________________________________
Provider’s Address:
____________________________________________________________________
STREET
__________________________________________
_____ _______________
CITY
STATE
ZIP
Contact Name: __________________________________________________
Tel: (_______) ________ - __________
Fax (_______) _______ - ___________
Email: _____________________________________________________
Check one:
□ Individual Provider
□ Company Provider
COURSE INFORMATION
□ ATTACH a detailed outline or agenda of the course must be attached to application
Subject (Check ONLY ONE) :
□ Microdermabrasion
□ Electric Nail File
□ Eyelash Extensions
Name of Course: _______________________________________________________
Clock Hours: _________
All continuing education in South Dakota must emphasize safety and sanitation
Do not include breaks and meals
Location of Course:
_______________________________________
______________________________
BUSINESS NAME
STREET
__________________________________________
_____ _______________
CITY
STATE
ZIP
Initial Course Offering Date: ____________________ Time:________________________
ADDITIONAL OFFERINGS
If this course will be offered more than the initial date listed above, attach a list of dates, times, and locations. To
identify the location, include business name, address, city, state, and zip code.
The Commission must have at least twenty-four (24) hours written notice of any changes in the date, location or
instructor of your course. Resumes are required for a new course instructor. This information must be faxed to the
number above. All correspondence MUST include the Commission assigned Course Certification number, course name
and number of credit hours.
Instructor Name: _______________________________________________________________________
QUALIFICATIONS AND LICENSURE
□ ATTACH instructor’s resume
□ List state(s) of licensure and current license number
An instructor does not
have to be licensed in South Dakota, but must be licensed from another state.
DLR COSMETOLOGY PROVIDER APPLICATION
8/2018
SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
SOUTH DAKOTA COSMETOLOGY COMMISSION
500 E Capitol Ave, Pierre, SD 57501
Tel: 605.773.6193
Fax: 605.773.7175
cosmetology.sd.gov
EDUCATION CERTIFICATION COURSE PROVIDER APPLICATION
APPLICATION FEE: $100
(Non-refundable)
Check or money order payable to: Cosmetology Commission
GENERAL PROVIDER INFORMATION
Provider’s Name: _________________________________________________________________________
Provider’s Address:
____________________________________________________________________
STREET
__________________________________________
_____ _______________
CITY
STATE
ZIP
Contact Name: __________________________________________________
Tel: (_______) ________ - __________
Fax (_______) _______ - ___________
Email: _____________________________________________________
Check one:
□ Individual Provider
□ Company Provider
COURSE INFORMATION
□ ATTACH a detailed outline or agenda of the course must be attached to application
Subject (Check ONLY ONE) :
□ Microdermabrasion
□ Electric Nail File
□ Eyelash Extensions
Name of Course: _______________________________________________________
Clock Hours: _________
All continuing education in South Dakota must emphasize safety and sanitation
Do not include breaks and meals
Location of Course:
_______________________________________
______________________________
BUSINESS NAME
STREET
__________________________________________
_____ _______________
CITY
STATE
ZIP
Initial Course Offering Date: ____________________ Time:________________________
ADDITIONAL OFFERINGS
If this course will be offered more than the initial date listed above, attach a list of dates, times, and locations. To
identify the location, include business name, address, city, state, and zip code.
The Commission must have at least twenty-four (24) hours written notice of any changes in the date, location or
instructor of your course. Resumes are required for a new course instructor. This information must be faxed to the
number above. All correspondence MUST include the Commission assigned Course Certification number, course name
and number of credit hours.
Instructor Name: _______________________________________________________________________
QUALIFICATIONS AND LICENSURE
□ ATTACH instructor’s resume
□ List state(s) of licensure and current license number
An instructor does not
have to be licensed in South Dakota, but must be licensed from another state.
DLR COSMETOLOGY PROVIDER APPLICATION
8/2018
List any relevant information you feel is necessary to assist the Commission in determining approval of this course.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ATTENDANCE VERIFICATION
Briefly explain the method of monitoring for course attendance. _____________________________________________
__________________________________________________________________________________________________
□ ATTACH a sample of the sign-in sheet. After the course, submit a copy to the Commission.
□ ATTACH a sample copy of the certificate of attendance the provider issues to the licensee as proof of attendance of
the course. The certificate must show name of course, name of attendee, dates of attendance, and number of hours
earned.
AGREEMENT
I certify all information on this application is correct to the best of my knowledge.
Person completing this application (Please print): __________________________________________________________
Signature: ______________________________________________________________ Date:_____/______/________
SUBMISSION
Submit your application within sixty (60) days prior to the course date to receive prior approval and a course number. A
$100 non-refundable fee must accompany the application. This fee is good for one year only no matter how many
courses are taught and is not pro-rated.
Attachments:
1. Course agenda or outline
2. Additional offerings
3. Instructor resume
4. Sample of sign-in sheet
5. Sample of certificate of attendance
NOTES
When South Dakota licensees attend an approved provider course, the licensee does not have to pay the $35
verification fee to the Commission.
As of January 1, 2005, the Commission only requires a one-time continuing education course for electric nail files
and microdermabrasion.
As of July 3, 2017, the Commission requires a one-time continuing education course for eyelash extensions.”
After the Commission has granted its written approval of the application, the provider is entitled to state upon
its publications: “This program is approved for ___ (number) South Dakota Education Certification Hours.”
COMMISSION USE ONLY
□ Approved
Hours :______
Course Approval Number: _________________________
□ Denied
Reason: ______________________________________________________________________________
Reviewed by: _______________________________________________________
Date: _____/_____/________
DLR COSMETOLOGY PROVIDER APPLICATION
8/2018
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