Authorized Representative Change Form
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1The Ohio State Board of Cosmetology
1929 Gateway Circle Grove City, Ohio 43123
Phone: (614) 466-3834 Fax: (614) 644-6880
Authorized Representative Change Form
Current Authorized Representative
Business License # (Required)
Name
Last Four Digits of Social Security Number: XXX-XX -
(Required)
Birth Date: _______/______/______
(REQUIRED)
MM
DD
YYYY
New Authorized Representative:
The Authorized Representative is the individual legally authorized to sign official
correspondence from the Board on behalf of the business.
Name:
Street Address:
City:
State:
Zip:
County:
Contact Number:
SSN:
Email:
(Required)
Notice on Collection of Personal Information
The Ohio State Board of Cosmetology collects personal information on this form principally to identify and evaluate an applicant’s qual-
ifications for licensure, issue and renew licensure and enforce the provisions of Section 4713 of the Ohio Revised Code. Submission of
this information is mandatory and the Board cannot process your application without a complete and accurate profile that includes the
information requested. Information submitted to the Board, excluding confidential personal information as listed under Section 149.43
of the Ohio Revised Code, may be disclosed in response to a request for public records, to another state or government agency as
required by law, or pursuant to a court order. Licensees may request to review the information maintained by the Ohio State Board of
Cosmetology. Questions should be directed to the Board office. The Ohio State Board of Cosmetology maintains personal information
data in an interconnected enterprise licensing data system that is accessed by other agencies authorized to engage in occupational
and professional licensing in the state of Ohio. Access to personal information data maintained in the interconnected enterprise licens-
ing system by participating agencies is strictly limited to purposes identified by each participant, in accordance with Section 1347.15 of
the Revised Code. I hereby request that in order to process my application, act upon renewal requests, and to respond to public re-
quests to confirm my license/certificate status, my personal information be accessed in accordance with OAC 4713-1-13(E) and (G).
Signature of New Authorized Representative
Date
Printed Name of New Authorized Representative
COS060 11042016
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Parent category: Business