Fillable Cosmetology, Esthetics, Nail Technology, And Electrology Establishment Renewal Form printable pdf download

Cosmetology, Esthetics, Nail Technology, and Electrology Establishment Renewal Form

FACILITY NAME: _____________________________

LICENSE NUMBER: _____________________________

ADDRESS:

_____________________________

*LICENSE EXPIRES:_____________________________

_____________________________

LICENSE TYPE:

COSMETOLOGY ______

ESTHETICS ______

_____________________________

NAIL TECHNOLOY ______

ELECTROLOY ______

*Licenses will not be renewed sooner than six (6) weeks in advance. Renewals submitted to the Board office sooner the six weeks prior to the expiration date of the

license will be returned to the licensee and will not be retained by the Board office.

You must notify the Board office if you have not received your license within 30 days of the date of your renewal or application submission. Failure to do

so may result in a $25 duplicate license fee.

NON-REFUNDABLE FEES

The above listed establishment license will soon expire. To renew your license, complete this form and return it to the Board office.

$ 50 fee for renewal licensure application submitted on-line or with a postmark prior to or on the expiration date of license.

$30 fee for delinquency licensure application submitted on-line or with a postmark within 60 days after the expiration date of license.

Failure to submit a renewal application and fee prior to 60 days past the expiration date requires the establishment to close.

FEE PAYMENT — FEES ARE NON-REFUNDABLE

Renewal applications submitted with a postmark on or before the expiration, require a $75 fee. Those submitted with a postmark after the expiration date requires a

To pay by check or money order, attach the fee to the front of this completed application. Checks or money orders shall be made payable to the Kansas Board of

Cosmetology. Credit card payment may be made by completing the below credit card information.

Payment Type: □ American Express □ Discover □ MasterCard □ Visa

_______________________________________

____________________

Credit Card Number

Expiration Date (mo/yr)

Fee Amount

___________________

____________________________

(_____) _______________

_ __________________________________

Card Holder's Zip Code

Card Holder’s Printed Name

Card Holder’s Signature

Daytime Phone

FELONY CONVICTION

Do you have a felony conviction? Yes ____ No_____ Dates of Conviction(s): ________________________________________

If this is the first time you have notified the Board of this conviction(s), attach a certified copy of all court documents outlining charges, convictions, sentencing, and discharge. Go to the KBOC website, complete and

attach the Felony Conviction Form and the Felony Monitoring Form (where applicable). Pursuant to KSA 65-1908, you must demonstrate that you have been sufficiently rehabilitated to warrant the public trust. Failure

to notify the Board of any additional or subsequent felony conviction(s) may result in disciplinary action.

ATTESTATION

By signing this form, I certify that I am the owner or authorized representative of this establishment, which is located at the address listed above, and request

renewal of my facility license.

Owner’s printed name: ______________________________________ Owner’s signature: ______________________________________

Date: _____________

Co-Owner’s printed name: ___________________________________Co-Owner’s signature: ____________________________________

Date: _____________

E-mail address: ________________________________________________________________

The Board is unable to accept incomplete applications. Failure to sign the attestation and/or submit the appropriate fee is an incomplete application. If a check or credit card payment is insufficient or denied, this is

also viewed as an incomplete application. Either situation requires the renewal application be returned for your completion. Thereafter should you return the form with a postmark after your expiration date, a $30

01052016

delinquent renewal fee is required.

Cosmetology, Esthetics, Nail Technology, And Electrology Establishment Renewal Form

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