Application For An Expired Texas Cosmetology License printable pdf download

Application For An Expired Texas Cosmetology License

EXAS

EPARTMENT OF

ICENSING AND

EGULATION

P.O. Box 12088 - Austin, Texas 78711-2157

(800) 803-9202 - (512) 463-6599 - FAX (512) 475-2871

- cs.cosmetologists@tdlr.texas.gov

PPLICATION

Application for An Expired Texas Cosmetology License

PURSUANT TO OCCUPATIONS CODE, CHAPTER 1602

RITE IN THE

REA

MMEDIATELY

ELOW

EVENT

FEE

PMT.

MONEY

FEE

RECEIPT NUMBER

CODE

AMOUNT

TYPE

License

$53.00

Fee

1. Applicant's Full Name:

Last (Family Name)

First (Given Name)

Middle

2. Applicant's Social Security No.:

_____ _____

_____ - _____ _____ - _____ _____ _____ _____

Note: If you have a Social Security Number, Section 231.302 of the Texas Family Code REQUIRES all applicants to disclose

their Social Security Number (SSN) when filing an application.

The SSN that is provided is confidential and is required to

enforce Child Support orders.

3. Do you have a Social Security Number?

(circle one)

YES

5. Gender:

4. Date of Birth:

MALE

FEMALE

(circle one)

Month

Year

Day

6. Mailing Address and Contact Information: (

)

USED FOR ALL CORRESPONDENCE

(P.O. Box is allowed for this address.)

Number, Street and Apt. No.

- OR -

P.O. Box Number

(

)

City

State

Zip Code

Country

Area Code

Phone Number

(

)

FAX Number

Area Code

Phone Number

E-mail Address ( for example)

7. Type of Exam/License Appying for: (circle one)

Operator

Manicure Specialist

Esthetician Specialist

Hair Braider Specialist

Hair Weaving Specialist

Wig Specialist

Eyelash Extension Specialist

8. Have you obtained a high school diploma or the equivalent of a high school

Diploma? (Not required for Hair Weaving or Braiding Specialist)

Yes ____ No ____

9. Have you ever been convicted of, or placed on deferred adjudication for, any misdemeanor or

felony, other than a minor traffic violation?

____ YES

____ NO (check one)

If YES, attach a “Criminal History Questionnaire” to this application. A Criminal History Questionnaire may be found at

/cosmet/cosmetforms.htm.

10. Have you ever had an occupational license, certification or registration suspended, revoked or

denied in any state? ____ YES

____ NO (check one)

Please note this is not referring to a driver’s license, but rather any type of work-related license, certification or registration.

If YES, attach a “Disciplinary Action Questionnaire” with this application. A Disciplinary Action Questionnaire may be found at

/cosmet/cosmetforms.htm.htm.

THIS FORM CONSISTS OF 2 PAGES

Application For An Expired Texas Cosmetology License

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