Personal Name Change Form - The Ohio State Board Of Cosmetology
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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
Personal Name 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. A copy of the documentation that supports the
name change must accompany this form.
Acceptable documentation may include but is not limited to the following:
Court Petition supporting a name change
Citizenship Documents
Marriage Certificate
Divorce Decree
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
A license with your name change will not be printed unless requested. To request a duplicate license with
your current name, go to , click on Forms and Applications and select “Duplicate
Personal License Application” located under the Personal Licensing tab.
NAME CHANGE
New Name:_____________________________________________________________________________
Previous Name: _________________________________________________________________________
Your State Board License Number (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
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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