Request For A Change In License Status
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1T
D
L
R
EXAS
EPARTMENT OF
ICENSING AND
EGULATION
P.O. Box 12088 - Austin, Texas 78711-2157
(800) 803-9202 - (512) 463-6599 - FAX (512) 475-2871
- cs.cosmetologists@tdlr.texas.gov
REQUEST FOR A CHANGE IN LICENSE STATUS
PURSUANT TO OCCUPATIONS CODE, CHAPTER 51
EVENT
FEE
PMT.
MONEY
FEE
RECEIPT NUMBER
CODE
AMOUNT
AMOUNT
TYPE
License
Fee
License #
DO NOT WRITE ABOVE THIS LINE
NOTE: A
I
M
B
T
P
I
.
LL
NFORMATION
UST
E
YPED OR
RINTED IN
NK
1. Indicate the appropriate box:
I would like to put my license on inactive status. I am aware that my license
must be renewed while it is on inactive status. (No fee)
I would like to activate my license. ($25.00 cashiers check or money order)
2. Full Name:
Last (Family Name)
First (Given Name)
Middle
3. Social Security No.:
_____ _____
_____ - _____ _____ - _____ _____ _____ _____
Note: If you have a Social Security Number (SSN), Section 231.302 of the Texas Family Code REQUIRES all applicants to disclose
their SSN when filing an application. The SSN that is provided is confidential and is required to enforce Child Support orders.
4. License Number:
License Expiration Date:
5. Mailing Address and Contact Information: (USED FOR ALL CORRESPONDENCE)
Number, Street and Apt. No.
- OR -
P.O. Box Number
(
)
City
State
Zip Code
Country
Phone Number
Area Code
FAX
(
)
E-mail Address ( for example)**
Area Code
Number
STATEMENT OF APPLICANT
I certify that I will comply with all applicable provisions of the Tex. Occ. Code, Chapters 51, 1602, and 1603; 16
Tex. Admin. Code, Chapter 60; and, the Cosmetology Administrative Rules, 16 Tex. Admin. Code, Chapter 83.
I understand that providing false information on this application may result in revocation of the license I am
requesting and the imposition of administrative penalties.
Date Signed
Signature of Applicant
**The Department will add your address to the Cosmetology e-mail notification list, which automatically provides information from
the Department on matters affecting Cosmetology. Your e-mail address is confidential pursuant to the Texas Public Information Act
and the Department will not share it with the public
TDLR Form COS (8/2013)
This document is available on the TDLR website at /cosmet/cosmetforms.htm
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