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□Application & Fee **FOR OFFICE USE ONLY** □Licensed for 5 yrs + □Employment History □ Photo Receipt # ID # Issue Date Apprentice Lic.# ELA Rhode Island Board of Examiners in Electrology Room 104 3 Capitol Hill Providence, RI 02908-5097 Instructions and License Application for: ELECTROLOGY INSTRUCTOR ‫‮‬ Applicant - Print Name (First/MI/Last) Phone: (401) 222-2828 Fax: (401) 222-1272 TTY/TDD: (800) 745-5555 DIVISION OF PROFESSIONAL REGULATION 3 CAPITOL HILL, ROOM 104 PROVIDENCE, RI 02908 (401) 222-2827/FAX (401) 222-1272 WWW.HEALTH.STATE.RI.US ELECTROLOGY INSTRUCTOR I HEREBY make application to the Office of Health Professions Regulation to be registered as an Electrology Instructor in accordance with the provisions of Section 5-32-4 of the General Laws as amended. NAME_____________________________________________________________________________ First Middle Last Maiden ADDRESS__________________________________________________________________________ Street City/Town State Zip Code TELEPHONE_________________ E-MAIL _____________________FAX______________________ Birth Date ______________________ SS#____________________________________ “Pursuant to Title 5, Chapter 76, of the Rhode Island General Laws, as amended, I attest that I have filed all applicable tax returns and paid all taxes owed to the State of Rhode Island, and I understand that my Social Security Number (SSN) will be transmitted to the Divison of Taxation to verify that no taxes are owed to the State.” Electrology License Number Issue Date: EMPLOYMENT HISTORY Please provide employment history for last 5 years) Name of Business Address From To Name of Business Address From To Name of Business Address From To Name of Business Address From To AFFIDAVIT State of Rhode Island, County of ______________________________ in ____________________in said county on this _____ day of _____________ 20___, personally appeared before me ___________________________________________________ _______________________ Signature of Applicant Notary Public My Commission Expires: _______________ SEAL Completing your Board Application: Complete all pages of the application. Do not submit applications without all applicable information, documentation and fee. Mail these components of the application to: Rhode Island Department of Health 3 Capitol Hill, Room 104 Providence RI, 02908-5097 HEALTH will not, for any reason, accelerate the processing of one applicant at the expense of others. Once completed, the application will be reviewed, and you will be contacted in writing. Please continue to review the remaining portions of this application packet for instructions and other materials necessary to complete the Board application. If you have any questions about this application process, or would like to check on the status of your Board application, please contact this office at (401) 222-2828. General Instructions 1. Make a copy of the application and forms before you begin, in case you make a mistake. 2. Type your information or print in blue or black ballpoint pen. Board staff will not make assumptions about illegible information. Be sure to print your name in the box provided on the cover page. 3. Provide a response to each section or question; otherwise, mark “N/A” for Not Applicable. 4. We suggest that you make a copy of your completed application before submitting it to the Board. 5. It is your responsibility to check on the status of your application. General Information Complete and submit application along with the following: 1.Completed application signed & notarized 2.Fee - $100 (check or money order made payable to the General Treasurer State of RI 3.Passport size photograph