Application For Duplicate Practitioner'S License
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1APPLICATION FOR DUPLICATE PRACTITIONER’S LICENSE
Complete this duplicate practitioner’s license application online, print, and mail to the Kansas Board of Cosmetology at the address
listed above. The below must be included with this completed form:
1.
The nonrefundable $25 fee.
2.
Legible photocopy of your current government issued photo identification. (i.e. drivers license, state identification card, or military identification)
License Type
Cosmetology
Body Piercing Technician
Apprentice
Nail Technology
Tattoo/Cosmetic Tattoo Artist
Electrology
Esthetics
Instructor
Body Art Trainer
Practitioner Information
Name: _______________________________________________________________________ whose mailing address is:
Last
First
Middle
_____________________________________________________________________ (_____) ____________________
(Street)
(City/State)
(Zip)
(Phone Number)
Email Address: _________________________________________
whose license number is: ________________________ and Social Security Number is: _______________________
wishes to apply for a duplicate of said license. Being duly sworn and deposed, I state my license has been (check
appropriate one):
□
Destroyed
□
Lost
□
Stolen - if stolen please attach a copy of the police report.
□
Never Received
□
Need a reprinted license due to name change - Enclose a copy of the legal document (i.e. marriage license, divorce decree, gov-
ernment issued ID/DL or other court document) which verifies the name change.
□
Working in more than one facility. List below each facility in which you are providing consumer services
:
Facility: ______________________________________________________Facility License #____________
Address: ________________________________________________________________________________
(Street)
(City)
Facility: ______________________________________________________Facility License #____________
Address: ________________________________________________________________________________
(Street)
(City)
Fee Payment $25
To pay the non-refundable $25 fee by check or money order, attach the fee to the front of this completed application. Check or money order shall be
made payable to the Kansas Board of Cosmetology. For credit card payment, complete the section below:
□
□
□
□
Payment Type:
American Express
Discover
Mastercard
Visa
_______________________________________
_________________
____________________
$
Credit Card #
Expiration Date (mm/yy)
Fee Amount
_______________________ _________
(_____) _______________
____________________________________
Card Holder's Zip Code
Card Holder’s Printed Name
Daytime Phone
Card Holder’s Signature
Attestation—At this point print this completed application
I declare under penalty of perjury under the laws of the State of Kansas that the information provided is true and correct .
Applicant's Signature: ___________________________________________
Date:____________________
Office Use Only: Approval Date:_______________
Authorization: ________________
11/20/2013
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