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| Question | Answer |
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| Form Name | Tdlr Salon Form |
| Form Length | 5 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 15 sec |
| Other names | tdlr texas gov applicationj, trace car license owner texas, texas license owner, tdlr salon |
T EX AS D EPART M EN T O F LI CEN SI N G AN D REGU LAT I O N
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P. O. Box 1 2 0 8 8 |
- Au st in , Te x a s 7 8 7 1 1 - 2 1 5 7 |
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(8 0 0 ) 8 0 3 - 9 2 0 2 - ( 5 1 2 ) 4 6 3 - 6 5 9 9 - FAX ( 5 1 2 ) 4 7 5 - 2 8 7 1 |
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w w w . tdlr.texas.gov |
- cs.cosm e t ologist s@tdlr.texas.gov |
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APPLI CATI ON FOR: |
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Te x a s Cosm e t ology St u de n t Pe r m it |
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PURSUANT TO OCCUPATI ONS CODE, CHAPTER 1602 |
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D O N OT W RI TE I N TH E FEE AREA I M M ED I ATELY BELOW |
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EV EN T |
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FEE |
PM T. |
M ON EY |
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FEE |
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RECEI PT N UM BER |
COD E |
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AM OUN T |
AM OUN T |
TYPE |
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Per m it |
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$ 25 . 00 |
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Fee |
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Pa y m e n t s m u st be in t h e for m of a ca sh ie r s ch e ck or m on e y or de r .
D O N OT W RI TE ABOV E TH I S LI N E
N OTE: ALL I NFORMATI ON MUST BE TYPED OR PRI NTED I N I NK.
1 . St u de n t ’s Fu ll N a m e :
Last ( Fam ily Nam e) |
Fir st ( Giv en Nam e) |
Middle |
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2 . D o y ou h a v e a Socia l Se cu r it y N u m be r ( SSN ) ? |
( cir cle one) |
YES |
N O |
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I f ye s, pr ov ide y ou r SSN h e r e : |
_____ _____ |
_____ - _____ |
_____ - _____ _____ |
_____ _____ |
Not e: I f y ou hav e a Social Secur it y Num ber ( SSN) , Sect ion 231 . 302 of t he Tex as Fam ily Code REQUI RES all applicant s t o disclose t heir SSN w hen filing an applicat ion . The SSN t hat is pr ov ided is confident ial and is r equir ed t o enfor ce Child Suppor t or der s.
3 . D a t e of Bir t h :
Mont h |
Day |
Year |
4 . Ge n de r : |
M ALE |
FEM ALE |
( cir cle one)
5 . St u de n t M a ilin g Addr e ss a n d Con t a ct I n for m a t ion : |
(Used for all correspondence) |
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Num ber , St r eet and Apt . No. - OR - P. O. Box Num ber |
Cit y |
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St at e |
Zip Code |
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( |
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) |
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E- m ail Addr ess ( j ohndoe@aol. com for ex am ple) |
Ar ea Code |
Phone Num ber |
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6 . Cosm e t ology Sch ool I n for m a t ion : |
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School Per m it Num ber |
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School Nam e |
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Num ber and St r eet |
Cit y |
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St at e |
Zip Code |
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7 . Cou r se Ty pe :
8 . En r ollm e n t D a t e :
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Ar e you e n r ollin g in a h igh sch ool cosm e t ology pr ogr a m ? |
( cir cle one) |
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YES |
N O |
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. H a v e y ou gr a du a t e d h igh sch ool or obt a in e d y ou r G. E. D ? |
( cir cle one) |
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YES |
N O |
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I f y e s: |
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School Nam e |
Cit y |
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St at e |
Dat e |
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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
Dat e Signed |
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St udent Signat ur e |
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Dat e Signed |
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I nst r uct or Signat ur e |
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License Num ber |
TD LR COS for m r e v 8/ 2 0 1 3 This document is available on the TDLR website at www.tdlr.texas.gov/cosmet/cosmetforms.htm