Louisville Beauty Academy - Student Leave of Absence

Louisville Beauty Academy - Student Leave of Absence - Request Form

State Board of Cosmetology and Hairdresser of Kentucky Template (All Fields Must be Completed)
Student Name*

First NameMiddle NameLast Name
Student State Board Permit ID*
Look at the school student permit board to find your student permit #
Cell Phone Number*

Area CodePhone Number
Student E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student of Program:*
Leave of Absence is between the dates below (201 KAR 12:123 Sec 17)
- (1) One Leave of Absence per (1) program
- No Longer than (6) six months
Leave Start Date*

MonthDayYear
Date
Leave End Date*

MonthDayYear
Date
Reason for the leave of absence: *
School Name: Louisville Beauty Academy

School License Number: 700047
Student Signature*

Clear
Today Date*

MonthDayYear
Date
School Owner(s) Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Louisville Beauty Academy - Student Leave of Absence - Request Form