HTML Preview Cosmetology Apprenticeship Application Form page number 1.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-9288
www.michigan.gov/bpl
BPLHelp@michigan.gov
NEW STUDENT AND APPRENTICE REGISTRATION APPLICATION
Authority: 1980 PA 299
Print or Type Clearly
School or Establishment Name
School or Establishment Permanent ID #
Establishment Address
City
State
Zip Code
Apprentice Name (First, Middle, Last)
Date of Birth
U.S. Social Security Number
Required Additional Documents
For a New Student
-
The number of hours accepted (if applicable).
-
The number of minimum practical application verified (if applicable).
NOTE: A cosmetology establishment which has successfully trained one (1) apprentice is eligible to train additional apprentices except that
a cosmetology
establishment shall not have more than two (2) apprentices at the same time.
Certification
I certify that the statements in this document are true and complete. I understand that any omitted statement, misrepresentation, or fraud
may be cause for
denial of my application, disciplinary action, or may be punishable by law. I agree the Department is required by law to obtain my social security number
pursuant to MCL 338.3434a.
Signature
Date
CHECK THE LICENSE/REGISTRATION TYPE
FOR OFFICE USE ONLY
$15.00 each
Student Registration
Apprentice Registration:
Cosmetologist Apprentice
$25.00 each
Electrologist Apprentice
$25.00 each
Esthetician Apprentice
$25.00 each
Manicurist Apprentice
$25.00 each
Natural Hair Culturist Apprentice
$25.00 each
2707-05
2701-14
2704-14
2705-14
2703-14
2702-14
License Number
Issue Date
Make your check or money order in U.S. Currency payable to:
STATE OF MICHIGAN
FEES ARE AUTHORIZED BY THE STATE LICENSE FEE ACT, 1979 PA 152 AND ARE NOT REFUNDABLE.
LARA/COSSTUD-APPR (Rev. 05/17)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability,
or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.