Form A450-1214_15EXLIC "Wax Technician - Wax Technician Instructor Examination & License Application" - Virginia

This version of the form is not currently in use and is provided for reference only.
Download this version of Form A450-1214_15EXLIC for the current year.

What Is Form A450-1214_15EXLIC?

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

Form Details:

  • Released on December 1, 2021;
  • The latest edition provided by the Virginia Department of Professional and Occupational 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 fillable version of Form A450-1214_15EXLIC by clicking the link below or browse more documents and templates provided by the Virginia Department of Professional and Occupational Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download Form A450-1214_15EXLIC "Wax Technician - Wax Technician Instructor Examination & License Application" - Virginia

Download PDF

Fill PDF online

Rate (4.4 / 5) 17 votes
Page background image
Commonwealth of Virginia
Department of Professional and Occupational Regulation
PSI Services LLC - Virginia Barber Cosmetology Program
P.O. Box 887
Wheat Ridge, CO 80034
Telephone No.: 1-855-229-9302
Virginia Board for Barbers and Cosmetology
Email:
vacos@psionline.com
WAX TECHNICIAN – WAX TECHNICIAN INSTRUCTOR
Website:
www.psionline.com
EXAMINATION & LICENSE APPLICATION
Instructions:
Applicants are encouraged to apply online at
https://vacos.useclarus.com/
If you are unable to apply online, complete this form and mail this application with a cashier's check, money order, or
credit card payment for the full amount of the examination fee, payable to PSI Services LLC at the address listed above.
Any applicant who does not pass a reexamination within one year of the initial examination date shall be required to
submit a new application and new examination fee.
Select one examination type you are requesting:
Examination Type
Fee
1214 - Practical & Theory Exam
$172.00
1214 - Practical Exam
$86.00
1214 - Theory Exam
$86.00
1215 - Instructor Exam
$86.00
1.
Full Legal Name
(As it appears on your government issued ID or other legal documentation.)
Last (required)
First (required)
Middle
Generation
2.
Provide at least one of the following identification numbers :
Social Security Number and/or
-
-
Virginia DMV Control Number
Enter the same identification number as used on examination, previous applications or licenses on file with the department.
State law requires every applicant for a license, certificate, registration or other authorization to engage in a business, trade, profession or occupation issued
by the Commonwealth to provide a social security number or a control number issued by the Virginia Department of Motor Vehicles.
3.
Date of Birth
MM/DD/YYYY
4.
Maiden or Former Name(s)
5.
Mailing Address (PO Box accepted)
The mailing address will be
printed on the license.
City
State
Zip Code
Check here if Street Address is the same as the Mailing Address listed above.
6.
Street Address (PO Box not accepted)
PHYSICAL ADDRESS REQUIRED
City
State
Zip Code
7.
Contact Numbers
Primary Telephone
Alternate Telephone
Fax
Email Address
8.
Email address is considered a public record and will be disclosed upon request from a third party.
DATE
FEE
TRANS CODE
ENTITY #
FILE #/LICENSE #
ISSUE DATE
OFFICE
12
USE
1020
ONLY
A450-1214_15EXLIC-v17
Board for Barbers & Cosmetology/WAX TECH & WAX INSTR EX LIC APP
12/01/2021
Page 1 of 4
Commonwealth of Virginia
Department of Professional and Occupational Regulation
PSI Services LLC - Virginia Barber Cosmetology Program
P.O. Box 887
Wheat Ridge, CO 80034
Telephone No.: 1-855-229-9302
Virginia Board for Barbers and Cosmetology
Email:
vacos@psionline.com
WAX TECHNICIAN – WAX TECHNICIAN INSTRUCTOR
Website:
www.psionline.com
EXAMINATION & LICENSE APPLICATION
Instructions:
Applicants are encouraged to apply online at
https://vacos.useclarus.com/
If you are unable to apply online, complete this form and mail this application with a cashier's check, money order, or
credit card payment for the full amount of the examination fee, payable to PSI Services LLC at the address listed above.
Any applicant who does not pass a reexamination within one year of the initial examination date shall be required to
submit a new application and new examination fee.
Select one examination type you are requesting:
Examination Type
Fee
1214 - Practical & Theory Exam
$172.00
1214 - Practical Exam
$86.00
1214 - Theory Exam
$86.00
1215 - Instructor Exam
$86.00
1.
Full Legal Name
(As it appears on your government issued ID or other legal documentation.)
Last (required)
First (required)
Middle
Generation
2.
Provide at least one of the following identification numbers :
Social Security Number and/or
-
-
Virginia DMV Control Number
Enter the same identification number as used on examination, previous applications or licenses on file with the department.
State law requires every applicant for a license, certificate, registration or other authorization to engage in a business, trade, profession or occupation issued
by the Commonwealth to provide a social security number or a control number issued by the Virginia Department of Motor Vehicles.
3.
Date of Birth
MM/DD/YYYY
4.
Maiden or Former Name(s)
5.
Mailing Address (PO Box accepted)
The mailing address will be
printed on the license.
City
State
Zip Code
Check here if Street Address is the same as the Mailing Address listed above.
6.
Street Address (PO Box not accepted)
PHYSICAL ADDRESS REQUIRED
City
State
Zip Code
7.
Contact Numbers
Primary Telephone
Alternate Telephone
Fax
Email Address
8.
Email address is considered a public record and will be disclosed upon request from a third party.
DATE
FEE
TRANS CODE
ENTITY #
FILE #/LICENSE #
ISSUE DATE
OFFICE
12
USE
1020
ONLY
A450-1214_15EXLIC-v17
Board for Barbers & Cosmetology/WAX TECH & WAX INSTR EX LIC APP
12/01/2021
Page 1 of 4
9.
Have you ever taken the Wax Technician or Wax Technician Instructor examination in Virginia?
No
Yes
If yes, provide the following examination information
Wax Technician Exam
Practical Exam
Theory Exam
(Month/Year taken)
(Month/Year taken)
Wax Technician Instructor Exam
Month/Year taken:
10.
Have you been previously licensed in Virginia as a practitioner or instructor in the fields of Barber, Master Barber,
Cosmetology, Nail Technician, or Wax Technician?
No
Yes
If yes, provide your license number and expiration date below
VA License Number
Expiration Date
11.
Which method are you using to qualify for the examination? Select only ONE.
Completion of an approved wax technician training program in a Virginia licensed waxing school or a Virginia
public school wax technician program approved by the Virginia Department of Education or training that is
substantially equivalent to the Virginia Program
Required Documentation: Attach a completed Training & Experience Verification Form
Completion of a wax technician training which is substantially equivalent to the Virginia program (at least 80% of
Virginia's required hours) that is obtained outside the Commonwealth of Virginia , but within the United States and
its territories
Required Documentation:
Attach a diploma or official school transcript indicating successful completion of a
substantially equivalent training program or written verification from the Licensing Board in the state where the training was received.
Completion of a wax technician course (consisting of less than 80% of training hours required in Virginia) and
five years of wax technician work experience.
Required Documentation: Attach a certificate, diploma or other documentation verifying successful completion of the wax
technician course and a completed Training Substitution Form documenting at least five years of wax technician work experience.
Virginia licensed cosmetologist, provide license number and expiration date
VA License Number
Expiration Date
Wax Technician training obtained in any Virginia state institution
Required Documentation: Attach a completed Training & Experience Verification Form
Two years of waxing experience in the United States armed forces
Required Documentation: Attach a completed Training & Experience Verification Form
Applying to take the Wax Technician Instructor examination
VA License Number
Expiration Date
Previously licensed in Virginia by examination and past the reinstatement period.
Required Documentation: Verification from the Virginia Board for Barbers and Cosmetology.
Endorsement applicant required to complete Virginia examination.
Required Documentation: Verification from the Virginia Board for Barbers and Cosmetology.
A450-1214_15EXLIC-v17
Board for Barbers & Cosmetology/WAX TECH & WAX INSTR EX LIC APP
12/01/2021
Page 2 of 4
12.
Do you hold a current or have you ever held a Barber, Master Barber, Cosmetology, Nail Technician, or Wax
Technician license, certification or registration issued by any state or territory of the United States (excluding Virginia)?
No
Yes
If yes, complete the following questions.
A.
List the following state/jurisdiction where a license, certification or registration has been issued:
License, Certification or
State/Jurisdiction
Expiration Date
Registration Number
B.
Are you in good standing as a licensed, certified, or registered professional for the states/
jurisdictions listed above?
Yes
No
If no, provide an original Certification of Licensure (dated within the last 60 days)
from each state/jurisdiction where you are not in good standing.
Certifications of Licensure, prepared by the state board or regulatory body must include: 1) the license/certification/registration number; 2) the initial
date of licensure; 3) the expiration date of the license 4) the means of obtaining licensure (i.e. exam, reciprocity, etc.) and the minimum requirement
that were met to qualify for licensure; and 5) all closed disciplinary actions resulting in a violation or undetermined finding. Certification must be
mailed directly to:
Board for Barbers and Cosmetology, 9960 Mayland Drive, Suite 400, Richmond, VA 23233-1485
13.
Have you ever been subject to a disciplinary action taken by any (including Virginia) local, state or national regulatory
body? This includes but is not limited to any monetary penalties, fines, suspensions, revocations, surrender of a
license in connection with a disciplinary action or voluntary termination of a license.
No
Yes
If yes, complete the
Disciplinary Action Reporting
Form.
14.
Have you ever had an application for licensure, certification or registration as a practitioner or instructor in the fields of
barbering, cosmetology, waxing, nail care, esthetics, body-piercing, or tattooing denied by any (including Virginia)
local, state or national regulatory body?
No
If yes, complete the
Denial of Licensure Reporting
Form.
Yes
15.
A.
Have you ever been convicted or found guilty, regardless of the manner of adjudication, in any jurisdiction of the
United States of any felony? Any plea of nolo contendere shall be considered a conviction.
No
Yes
If yes, complete the
Criminal Conviction Reporting
Form.
B.
Have you been convicted or found guilty, regardless of the manner of adjudication, in any jurisdiction of the
United States of any misdemeanor involving moral turpitude, sexual offense, non-marijuana drug distribution or
physical injury within the last two (2) years?
No
Yes
If yes, complete the
Criminal Conviction Reporting
Form.
A450-1214_15EXLIC-v17
Board for Barbers & Cosmetology/WAX TECH & WAX INSTR EX LIC APP
12/01/2021
Page 3 of 4
16.
Are you applying for a temporary permit?
No
Yes
If yes, your sponsor must complete and sign the following sponsorship statement:
I, the undersigned, agree to supervise all activities related to the practice of waxing for the
named applicant, and shall be responsible for his/her waxing activities during the time the
temporary permit is in force.
Printed Name of Sponsor
Signature of Sponsor
Sponsor's VA Wax Technician or Cosmetology License No.
17.
By signing this application, I certify the following statements:
I am aware that submitting false information or omitting pertinent or material information in connection with this
application will delay processing and may lead to license revocation or denial of license.
I will notify the Board of any changes to the information provided in this application prior to receiving the
requested license, certification, or registration including, but not limited to any disciplinary action or conviction of
a felony or misdemeanor (in any jurisdiction).
I authorize the Department to verify information concerning me or any statement in this application from any
person, or any source the department may contact. I also agree to present any credentials or documents
required or requested by the Department.
I authorize any federal, state or local government agency, current or former employer, or other individual or
business to release information which may be required for a background investigation.
 I have read, understand and complied with all the laws of Virginia related to this profession under the provisions
of Title 54.1, Chapter 7, of the Code of Virginia and the Virginia Board for Barbers and Cosmetology
Regulations.
Signature
Date
18.
Attach a professional passport compliant 2" x 2" color photo taken within the last 6 months to reflect your current
appearance. It must meet the following requirements:
sized so that your head is approximately 1 inch from the bottom of the chin to the top of the head
taken in front of a plain white background
be a full-face view, directly facing the camera with a neutral facial expression
Attach Photo Here.
Photocopy pictures are
not permitted.
A450-1214_15EXLIC-v17
Board for Barbers & Cosmetology/WAX TECH & WAX INSTR EX LIC APP
12/01/2021
Page 4 of 4
Page of 4