STATE OF WEST VIRGINIA - BOARD OF BARBERS AND COSMETOLOGISTS
  1716 Pennsylvania Avenue, Suite 7, Charleston, WV 25302
Phone (304) 558-2924   Fax (304) 558-3450
E M P L O Y M E N T   C E R T I F I C A T I O N

  PLEASE NOTE: THIS FORM IS NOT TO BE COMPLETED BY APPLICANT. It is to be completed by  applicant’s employer if  possible; if not, any reputable person other than an immediate family member will be accepted.  The person completing this form MUST SIGN IN THE PRESENCE OF A NOTARY.

                                                         (PLEASE TYPE OR PRINT LEGIBLY)

       Applicant’s Name:                                                                                                                   

       Check Profession:   (   ) barbering    (   ) cosmetology    (   ) manicuring    (   ) aesthetics

                      Employer:                                                                                                                  

                       Address:                                                                                                                   

                               City:                                                             State:                Zip:                       

         Dates Employed:              /           /              To            /           /         

         Total Time Worked:                     Yrs.                        Mos.

  NOTARIZED SIGNATURE

      I hereby certify that the information given above is true in every respect.  My name, address, phone and signature listed below.

                     Name:                                                                      Phone:                                

                 Address:                                                                                                                 

                                                                                                                                                

               Signature:                                                                                   

State of                                            )
                                                        )

County of                                         )

      The above named, whose signature appears hereon, first being duly sworn, deposes and says that all of the above statements are true in every respect.
       Subscribed and sworn to before me this the           Day of                               , 19        .
My commission expires                                                           .

                                                                                                                                               

                                                                                        (Notary Public Signature)

© 2002 West Virginia Board of Barbers and Cosmetologists