STATE OF WEST VIRGINIA

BOARD OF BARBERS AND COSMETOLOGISTS

1716 Pennsylvania Avenue, Suite 7, Charleston, West Virginia 25302

Phone (304) 558-2924 Phone/Fax (304) 558-3450

REQUEST FOR CERTIFICATION OF LICENSE

The following information is required in order to process a certification of license. Please complete this form in its entirety, enclose the certification fee of $25.00 and return to the West Virginia State Board of Barbers and Cosmetologists at the address above. The certification will be mailed directly to the State Board where you are applying for licensure. A copy will be sent to you if so requested.

Name: License No.

Address:

SSN:

Indicate here the state to which you need the certification mailed to:

Check here if you desire a copy of the certification be sent to you: o

Date Signature of Licensee