To be completed by the licensed cosmetology supervisor at program completion.
Apprentice Name
Host Salon Name
Supervisor Name
Supervisor License Number
Program Start Date
Program End Date
Check each item to confirm completion. All items must be checked before submitting.
Apprentice has completed all required OJT hours (1,500 minimum)
All monthly OJT evaluations have been submitted to Program Sponsor
Apprentice has demonstrated all competencies in the scoring rubric
Apprentice has maintained professional conduct throughout the program
Apprentice is ready to sit for the Indiana State Board examination
All required compliance documents have been submitted
No outstanding remediation requirements remain
Supervisor Declaration
I, the undersigned licensed cosmetologist, attest that the above apprentice has satisfactorily completed all requirements of the Indiana DOL Registered Cosmetology Apprenticeship program and is prepared to sit for the Indiana State Board examination.
Supervisor Signature
Date
Program Sponsor Representative
Date
