Board of Barber Examiners P.o. Box 11329, Columbia, SC 29211-1329 Telephone (803) 896-4588 Fax (803) 896-4484

Student Permit Application Instructions

1.

Application must be printed in ink or typed.

2.

Application must be signed by student, School Official or Shop Instructor and notarized. Your application is not complete without these signatures.

3.

Read each area very carefully. If any information is not marked or questions unanswered, your application may be returned for incompleteness.

4.

You must attach proof of having completed at least the ninth grade or better. If you do not mail this information along with the fee and application it will be marked as incomplete and will be returned to you.

5.

A skin test or chest x-ray must be accompanied with all applications. It must indic te you are free of tuberculosis.

6

Mail the completed application and a check or money order for $35 and other required documents (proof of completion of 9th grade) to: South Carolina Department of Labor, Licensing and Regulation Board of Barber Examiners Post Office Box 11329 Columbia, SC 29211-1329

All applications will be returned if not properly c mpleted or fees not enclosed.

Please notify the SC Board of Barber Examiners office at (803) 896-4588 if you feel you are eligible unde theAmericans with Disabilities Act (ADA) for special accommodation either in completing the application process or in takin the required examinaion. Rev. 02/11

South Carolina Department of Labor, Licensing and Regulation

Board of Barber Examiners RETURN FORM TO:

Board of Barber Examiners Attach in this space head and shoulders photograph of applicant taken in the last six months 1 112" x 1 112"

FOR OFFICE USE ONLY

Synergy Business Park 110 Centerview Drive Post Office Box 11329 Columbia, South Carolina 29211-1329 Phone: (803) 896-4588 Fax: (803) 896-4484 Internet Address: www.llr.state.sc.us

Permit Issue Date:

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Permit Expiration Date:

_

Amount Rec'd:

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_ Check _

Money Order _ Cash

STUDENT PERMIT APPLICATION

]

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FEE REQUIRED:

$35. Submit a cashier, personal or certified check or money order payable to the SC Department of Labor Licensing and Regulation Board of Barber Examiners. 1. STUDENT INFORMATION Name:

_ First

*Address:

Last

Middle

-------------------------------------------Number

Street

City

*Telephone No: llighSchool

Zip

State

_

County

Date of Birth:

_

Attended:

_ (You must attach proof that you have completed at least the 9th grade.)

___ Copy ofH.S. Diploma

GED

__

H.S. Transcript

__

College Transcript

__

Previous Barber Training

College Diploma

Other

_ Dates of Training

School or Instructor

Hours Completed

I understand that any omission, inaccuracy or failure to make full disclosure in this application may be deemed suficient reason to withhold, suspend or revoke a license issued by the Board. I understand that the Board may make such inquiry and investigation concemiig my record or background as the Board in its judgement deems proper I further agree to furnish any additional information requested by the Board. I affirm that I am the applicant named herein and that the answers and information contained herein are true to the best of my knowledgeand belief.

All information in this document is a matter of public record subject to disclosure pursuant to the of Information Act, except items designated with this symbol (*).

S.c. Freedom

Date

Signature of Applicant

Page 1 of2 Rev. 03/11

HEALTH CERTIFICATION Prior to licensure, applicant shall be required to have a tuberculin skin test with five U.S. Tuberculin Units of purified protein derivative. Applicants found to be non-reactors to a 5TU-PPD tuberculin skin test shall require no further routine annual screening. Results of skin tests utilizing the multiple puncture method shall not be accepted, If applicants are found to be tuberculin reactors, they must provide the Board with a statement that the applicant is non-contagious and must undergo such further testing as may be necessary before the county health department or private physician can provide the Board with such a statement. This statement shall include a section stating whether or not it will be necessary for the applicant to have an annual chest x-ray.

Name of person being examined

Date

Result of Tuberculosis Examination:

X-Ray of Chest of Skin Test (attachreport)

...--

Ifind this applicant free from infectious tuberculin disease and is physically barbering.

Phone

QUr' lified to practice

Print Name of MD.

Signature of MD.

Address

_

City

State

Zip

MD. License Number

County

AFFIDAVIT OF ELIGIBILITY Pursuant to section 8-29-10 of the South Carolina Code of Laws (1976 as amended), the Department of Labor, Licensing and Regulation must verify the lawful U.S. presence of any person who applies for a South Carolina license. Please complete and sign this Affidavit of Eligibility. The information provided is subject to verification. Section A: LAWFUL PRESENCE in the United States. I, (please print your full name) , swear or affirm under penalty of perjury under the laws of the State of South Carolina that (check 1,2 or 3 below): 1.

I am a United States citizen or legal permanent resident eighteen years of age or older; or

2.

I am not a US citizen but am lawfully present in the US as evidenced by one of the following a. _ I am a qualified alien as defined in 8 U.S.C. see 1641, eighteen years of age or older. b. _ I am a nonimmigrant under the "Immigration and Nationality Act," Federal Public Law 82-414 as amended, eighteen years of age or older.

3.

I am not physically present in the US under 8 U.S.C. see 1621 (c) (2) (c) or employed in the US pursuant to 8 U.S.C. 1621 (c) (2) (a) (check either a or b below): a. _ I am a US citizen, not physically present or employed in the United States. b. _ I am a Foreign National, not physically present or employed in the United States.

If you selected either 3.a. or 3.b., you do not need to complete Section B. Skip to Section C. Section B: Secure and Verifiable Document. This section must be completed if you checked number 1 or 2 in Section A. 1.

Please check the acceptable secure and verifiable document(s) you hold. A copy ofthe verifiable document(s) must be attached to the Affidavit of Eligibility.

o

o o o

A valid South Carolina Driver's License, South Carolina Driver's Permit rr South Carolina Identification Card. Number ; Date of Expiration: ---f---A valid out-of-state issued photo Driver's License or photo identification ard, photo driver's permit. State: ; Number Date of Expiration: --t--Permanent Resident Card; Alien Number Date of Expiration: _ Employment Authorization Card; Alien Number _____ ; Date of Expiration:

o

Certificate of Naturalization with intact photo.

o

Certificate of (US) Citizenship with intact photo.

o

Other: (Name of verifiable document)

_

Card Numb1er

_

I

; Card Nrmber _

+-

_

2. Enter the state or the federal agency name where the secure and verifiable document/ s) was issued.

(If issued by a state agency, include both the state and agency name.)

3. Please provide your social security number:

/

/

(Include a copy ofthe card with the Affidavit)

Section C: Attestation. •

I understand that this sworn statement is required by law because I have applied for or seek reinstatement of a professional or commercial license as provided for in 8 V.S.C. §1621. I understand that state law , requires me to provide proof that I am lawfully present in the United States.

•

I understand that in accordance with section 8-29-10 of the South Code, a person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a felony.

•

I am the person identified above, and the information contained herein is true and correct to the best of my knowledge. I understand that under South Carolina law, providing false information is grounds for denial, suspension or revocation of a license, certificate, registration or permit.

Signature

Date

Please print your name as shown on your secure and verifiable document. Professional License Type: License Number (if already licensed):

_ _

The South Carolina Law requires that every individual who applies for an occupational or professional license provide a social security number for use in the establishment, enforcement and collection of child support obligations and for reporting to certain databanks established by law. Failure to provide your social security number for these mandatory purposes will result in the denial of your licensure application. Social security numbers may also be disclosed to other governmental regulatory agencies and for identification purposes to testing providers and organizations involved in professional regulation. Your social security number will not be released for any other purpose not provided for by law.

06/28/12

Affidavit of Eligibility