Fill and Sign the Standard Quotation and Specification Form Virginia

ARKANSAS DEPARTMENT OF HEALTH COSMETOLOGY SECTION 4815 West Markham, Slot 8 Little Rock, AR 72205 (501) 682-2168 INSTRUCTIONS: File this application when applying for a new establishment license. This form is to be filed approximately two (2) weeks before your opening date. You will receive a letter of authorization, to be posted in the reception area, that will allow you to open and operate said salon until such time it is inspected. THIS FORM MUST BE SUBMITTED WITH: $150 NEW ESTABLISHMENT FEE NEW ESTABLISHMENT REGISTRATION Please PRINT using blue or black ink only. If requested information is not applicable please respond N/A. ESTABLISHMENT INFORMATION 1 Establishment Name 2 Telephone Number ( ) (If a rural route or Post Office Box please provide directions on reverse side.) 3 Address Where Establishment Receives Mail Suite. # City County State Zip Code 4 Physical Address of Establishment Suite. # City County State Zip Code 5 7 Type of Establishment COSMETOLOGY MANICURE ELECTROLOGY AESTHETICIAN 6 Opening Date (CIRCLE ONE) Days Open (CIRCLE ALL THAT APPLY) SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY OWNER INFORMATION 8 Is the owner a Corporation? YES If yes, name of corporation: (also complete items 11 & 13) If no, is owner licensed? NO YES Id Number License Number NO Complete the following information regarding the owner. 9 Last Name First Name (no nicknames) Date of Birth Gender MALE Race (Circle One) Middle Name 10 SSN 11 Address Where You Receive Mail Apt. # City County State Zip Code 12 Address Where You Live Apt. # City County State Zip Code 13 Phone ( ) FEMALE Black White Am. Indian Hispanic Asian Alaskan Native Email Address (REQUIRED) Applicant Signature: By signing this application, I certify that the information provided is correct to the best of my knowledge, and I am the establishment owner or am authorized to act as the owner’s agent. Further, I understand that false statements will be sufficient grounds for the Cosmetology Technical Advisory Committee to take disciplinary action. I have read this form, the laws and the rules and have complied with them during this process. In addition, I agree to close the establishment in the event that the Cosmetology Inspector determines that the establishment is not in compliance with the applicable laws and rules. Owner's Signature Today’s Date FOR OFFICE USE ONLY ID NUMBER RECEIPT NUMBER DATE PROCESSED