State and Consumer Services Agency – Governor Edmund G. Brown Jr.
Board of Barbering and Cosmetology
PO Box 944226, Sacramento, CA 94244
P (800) 952-5210 F (916) 575-7281 | www.barbercosmo.ca.gov
FOR CASHIERING USE ONLY $________________ Rec. # _______________
ATS # ___________ Postmark Date _________
LICENSE RENEWAL
Mail this form and a separate check or money order (do not send cash) with the applicable fee for each renewal to the address above. Make payable to the Board of Barbering & Cosmetology (Incomplete forms will not be processed).
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LICENSEE INFORMATION |
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License Type & Fee |
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License Number |
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if postmarked |
If postmarked |
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Letter(s): |
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on or before |
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after |
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expiration date: |
expiration date: |
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Numbers: |
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Cosmetologist $50.00 |
$75.00 |
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Barber |
$50.00 |
$75.00 |
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Last 4 digits of your Social Security Number: |
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Electrologist |
$50.00 |
$75.00 |
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(not required for establishments) |
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Manicurist |
$50.00 |
$75.00 |
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Esthetician |
$50.00 |
$75.00 |
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Date of Birth: |
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Establishment $40.00 |
$60.00 |
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(not required for establishments) |
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- |
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- |
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Mobile Unit |
$40.00 |
$60.00 |
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Month |
Day |
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Year |
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Last Name |
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First Name |
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Middle Name |
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Salon Name (if applicable) |
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If your address has changed do you want the Board to update our records with your current address? |
Yes |
No |
Important Notice: Changing the address on an establishment or mobile unit is prohibited without applying for a new |
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license; contact the Board or visit the Board’s Web site to acquire an establishment application. |
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Current Address |
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City |
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Phone Number |
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Email Address (not required) |
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State |
Zip Code |
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( |
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IMPORTANT INFORMATION (Please Read Carefully)
Processing Times: License renewals may take up to 8 weeks. Allow sufficient time so that you are not working with an expired license. It is illegal to work without a valid, unexpired license.
If you have a name change, please include a current copy of government-issued photographic identification (e.g., driver’s license, passport, alien registration, etc.) AND one of the following: certified court order, marriage certificate, dissolution of marriage, certified declaration of domestic partnership, or notarized document verifying name change.
LICENSEE CERTIFICATION
I certify under penalty of perjury under the laws of the State of California that all statements furnished in connection with this application are true and accurate and that I have not changed my address for the purpose of fraud.
INFORMATION COLLECTION, ACCESS AND DISCLOSURE
*This statement is for your information.
The Information Practices Act, Sec. 1798.17 Civil Code, requires the following information to be provided when collecting information from individuals.
AGENCY NAME:
Board of Barbering and Cosmetology
TITLE OF OFFICIAL RESPONSIBLE FOR INFORMATION MAINTENANCE:
Executive Officer
ADDRESS:
2420 Del Paso Road, Suite 100, Sacramento, CA 95834
INTERNET ADDRESS:
www.barbercosmo.ca.gov
TELEPHONE AND FAX NUMBERS:
(916) 574-7570 phone (916) 575-7281
AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE INFORMATION:
Sections 7300 to 7457, inclusive, comprising Chapter 10 Division 3, of the California Business and Professions Code.
CONSEQUENCES OF NOT PROVIDING ALL OR ANY PART OF THE REQUESTED INFORMATION:
It is mandatory that you provide all information requested. Omission of any item of requested information will result in the application being rejected as incomplete.
PRINCIPAL PURPOSE(S) FOR WHICH THE INFORMATION IS TO BE USED:
The information requested will be used to determine qualifications for licensure or certification to determine compliance with the group and corporate practice provisions of the law and to establish positive identification.
ANY KNOWN OR FORESEEABLE DISCLOSURES WHICH MAY BE MADE OF THE INFORMATION: Your completed application becomes the property of the board and will be used by authorized personnel to determine your eligibility for a license or certification. Information on your application may be transferred to other governmental or law enforcement agencies. Pursuant to the California Public Records Act (Gov. Code Section 6250 et seq.) and the Information Practices Act (Civ. Code Section 1798.61), the names and addresses of persons possessing a license or registration may be disclosed by the department unless otherwise specifically exempt from disclosure under the law.
Consequently, the personal name and address information entered on the attached form(s) may become public information subject to disclosure
SOCIAL SECURITY NUMBER (SSN) DISCLOSURE:
Disclosure of your social security number is mandatory. Section 30 of the Business and Professions Code and Public Law 94-455 [42 U.S.C.A. Section 405(c)(2)(C)] authorize collection of your social security number. Your social security number will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order for family support in accordance with section 17520 of the Family Code, or for verification of licensure or examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security number, you will be reported to the Franchise Tax Board, which may assess a $100 penalty against you.
