Personal Address Change - The Ohio State Board Of Cosmetology Form

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The Ohio State Board of Cosmetology
1929 Gateway Circle Grove City, Ohio 43123
Phone: (614) 466-3834 Fax: (614) 644-6880
Personal Address Change Form
(This form cannot be used for salon, tanning, or school facility changes, a Business Application must be submitted)
Complete this form and submit to the Board office if you have a change of address.
Submit completed form by:

Mail: Ohio State Board of Cosmetology 1929 Gateway Circle Grove City, Ohio 43123.
Fax 614-644-6880
Email to: Ohiocos@cos.ohio.gov
Name_________________________________________________________________________________
Your State Board License Number (Required): _________________________________
Birth Date: ______/______/_________
Email address
: _________________________________________________________
MM
DD
YYYY
ADDRESS CHANGE
New
Address_______________________________________________________________________________
City: ______________________________________ State: _________________Zip Code: _____________
County: ________________________________________Telephone Number: ____- _____- ____________
Old Address: ____________________________________________________________________________
City:_______________________________________ State:________________ Zip Code:_______________
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
qualifications for licensure, issue and renew licensure and enforce the provisions of Section 4713 of the Ohio Revised Code. Submis-
sion of this information is mandatory and the Board cannot process your application without a complete and accurate profile that in-
cludes 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 govern-
ment agency as required by law, or pursuant to a court order. Your social security number is required by state law and federal law for
purposes of child support enforcement (ORC 3123.50, 42 U.S.C. Section 666). 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 Cos-
metology maintains personal information data in an interconnected enterprise licensing data system that is accessed by other agen-
cies authorized to engage in occupational and professional licensing in the state of Ohio. Access to personal information data main-
tained in the interconnected enterprise licensing system by participating agencies is strictly limited to purposes identified by each par-
ticipant, 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 requests to confirm my license/certificate status, my personal information be accessed in
accordance with OAC 4713-1-13(E) and (G).  
_________________________________________________________________________________________________________________
Signature
Date
10072016

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