Verification of Experience gained outside the Commonwealth of Virginia
Commonwealth of Virginia
Department of Professional and Occupational Regulation
PSI Services LLC - Virginia Barber Cosmetology Program
P.O. Box 887
Wheat Ridge, CO 80034
Telephone No.: 1-855-229-9302
Website: www.psionline.com
Virginia Board for Barbers and Cosmetology
Barber, Master Barber, Cosmetology, Nail Technician and Wax Technician Only -
EXPERIENCE VERIFICATION FORM
Barber/Cosmetology -
A450-1213EXP-v2 Board for Barbers and Cosmetology/BC - EXP VER FORM
07/22/2022 Page 1 of 2
Section A - To be completed by the applicant.
Section B - To be completed by one of the individuals listed below who will verify the applicant's work experience.
* If "self-employment" is chosen, your experience may be reviewed by the Board and this will result in a delay of your
application being processed.
1. Salon/Shop Owner
2. Salon/Shop Manager/Supervisor
3. Licensed Barber/Master Barber/Cosmetologist/Nail Technician/or Wax Technician
4. Self-Employment * :
Section A: Applicant
1. Full Legal Name
(As it appears on your government issued ID or other legal documentation.)
Last (required)
First (required)
Middle Generation
2. Provide one of the following identification numbers :
Social Security Number and/or
Virginia DMV Control Number
State law requires every applicant for a license, certificate, registration or other authorization to engage in a business, trade, profession or occupation issued
by the Commonwealth to provide a social security number or a control number issued by the Virginia Department of Motor Vehicles.
Enter the same identification number as used on examination, previous applications or licenses on file with the department.
--
3.
Mailing Address (PO Box accepted)
City State Zip Code
4. Contact Numbers
Primary Telephone Alternate Telephone
Email Address
Email address is considered a public record and will be disclosed upon request from a third party.
5.
6. Select the License type you are applying for:
Barber Master Barber Cosmetology
Nail Technician Wax Technician
I, the undersigned, certify that the foregoing answers and statements are true, and that I have not suppressed any
information that might affect the Board's decision to approve this application. I also understand that providing false
information may result in denial of a license or possible disciplinary action.
7.
Applicant's Signature Date
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A450-1213EXP-v2 Board for Barbers and Cosmetology/BC - EXP VER FORM
07/22/2022 Page 2 of 2
Section B: Verifier (Completed by an individual who can attest to the applicant's experience listed above in Section A.)
1. Verifier's Information:
Name
Mailing Address
City State Zip Code
Contact Number Email Address
2. Indicate which of the following best describes your relationship to the applicant: (Select all that apply)
Salon/Shop Owner
Salon/Shop Manager/Supervisor
Licensed Professional:
License Number
State/Jurisdiction
Barber CosmetologistMaster Barber Nail Technician Wax Technician
Client for self-employed applicant (if requested by the board)
3.
This verification form is used as a means for the Board to verify that an applicant has the experience necessary to become a licensed
barber, master barber, cosmetologist, nail technician or wax technician within the Commonwealth of Virginia. Your response is
appreciated.
In your own words, describe the applicant's work duties (experience) for which you have been asked to attest:
4.
A.
B.
Where did the applicant gain this experience described above in question #3?
Name of Salon/Shop
Salon/Shop License No.
Zip Code
Salon/Shop Address
City State
C.
5.
Provide the date(s) of when this experience was obtained:
6.
I certify, to the best of my knowledge, all information provided on this form is true and accurate. I understand that
providing false information may result in the applicant being denied a license or possible disciplinary action brought
against them.
Verifier's Signature Date
