Fillable Printable Cosmetology, Hair Design, Barber, Manicurist, Esthetician Or Master Esthetician Apprentice Salon Shop Data Sheet
Fillable Printable Cosmetology, Hair Design, Barber, Manicurist, Esthetician Or Master Esthetician Apprentice Salon Shop Data Sheet
Cosmetology, Hair Design, Barber, Manicurist, Esthetician Or Master Esthetician Apprentice Salon Shop Data Sheet
Department use only
Issue date Exp. date Status
Department approving signature Date
X
Cosmetology, Hair Design, Barber,
Manicurist, Esthetician, or
Master Esthetician Apprentice
Salon Shop Data Sheet
Send this completed form to:
Cosmetology
Department of Licensing
PO Box 9026
Olympia WA 98507-9026
For additional information visit our website at dol.wa.gov
Salon information
PRINT or TYPE Salon shop name Salon shop license number
Business mailing address (Address, City, State, ZIP code)
Business physical address (Address, City, State, ZIP code)
(Area code) Business telephone number (Area code) Fax number Email
Business owners names (Last, First, Middle)
Total number of hours required for course completion
Curriculum 1
Cosmetology Hair Design Barber Manicurist Esthetician Master Esthetician
Curriculum 2
Cosmetology Hair Design Barber Manicurist Esthetician Master Esthetician
Authorized trainers
Last name First name Middle name License no.
I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Date and place Signature
BC-638-079 (R/1/16)WA
X
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When you have completed this form, please print it out and sign here.
