Request For Licensure Or Training/education Verification Form
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1REQUEST FOR LICENSURE OR TRAINING/EDUCATION VERIFICATION
Instructions: Read this form carefully and complete only the sections that apply to your request. Complete the form online,
print, sign, and return to the above address along with the $20 non-refundable fee.
Cosmetology
Body Piercing Technician
Apprentice
Nail Technology
Tattoo/Cosmetic Tattoo Artist
Electrology
Esthetics
Instructor
Body Art Trainer
NAME: _____________________________________________________________________________________
Last
First
Middle
ADDRESS: ___________________________________________________________________________________
Street
City
ST
Zip
EMAIL: __________________________________
PHONE NUMBER: (____)____________________
DATE OF BIRTH: ___________________________
SOCIAL SECURITY #: ______________________
MM/DD/YYYY
Disclosure is mandatory for licensure and authorized by KSA 74-148 to verify identity
Licensure Verification
If you are requesting verification of your Kansas practitioner license be sent to another state, complete this section:
License Number(s): __________________________
Send verification to: __________________________
A $20 fee is required for each license verified
Training/Education Verification
If you are requesting verification of your training or education in Kansas, complete this section:
Send verification to the following State: ____________________________
Send verification to the following School: ________________________________________
Address: _____________________________________________________________
FEE PAYMENT:
The $20 non-refundable fee shall be made by check or money order made payable to the Kansas Board of
Cosmetology, or by credit card payment below:
Payment Type:
American Express
Discover
Mastercard
Visa
_______________________________________
_________________
____________________
Credit Card Number
Expiration Date
Fee Amount
____________________ _____________
(____) ___________
_______________________________
Card Holder's Zip Code
Card Holder’s Printed Name
Daytime Phone
Card Holder’s Signature
ATTESTATION:
I declare under penalty of perjury under the laws of the State of Kansas that the information provided on this form is true
and correct.
_________________________________________
___________________________
Signature
Date
11/20/13
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