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Inactive Fees New Jersey Ofce of the Attorney (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Cosmetology and Hairstyling
124 Halsey Street, 6th Floor, P.O. Box 45003
Newark, New Jersey 07101
(973) 504-6400
Inactive Fees
Expiration date Fees Total fee required
Inactive Expired
November 1, 2018
$90.00 License fee
$50.00 Reinstatement fee
$140.00
Inactive
(prior to November 1, 2018)
$90.00 License fee $90.00
Please note
If your New Jersey cosmetology license has been placed in the “Inactive” status prior to
November 1, 2018 the fee is $90.00, after November 1, 2018 the fee is $140.00.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Cosmetology and Hairstyling
124 Halsey Street, 6th oor, P.O. Box 45003
Newark, New Jersey 07101
(973) 504-6400
Application to Reactivate an Inactive License
You may not practice in the State of New Jersey until your license has been reactivated.
Date:____________________________
Check all that apply:
Cosmetologist-Hairstylist Manicurist Skin Care Specialist Barber Beautician
N.J. License No.: ___________________________________ Date license became inactive: ____________________________
Initial license date: _________________________________
Please submit with this application a check or money order for $90.00, made payable to the State of New Jersey, which is the renewal
fee for the current biennial period (see N.J.A.C. 13:28-5.1(a)6). (Applicants should understand that if the application ling fee is paid
with a personal check, and the check is returned by the bank due to insufcient funds, the next step in the reinstatement process will be
delayed until the fee is paid). If your license became inactive more than ve(5) years ago, you must retake and pass the licensure
exam.
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records
Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information
Date of birth: _________________________________
Month Day Year
1. Name ________________________________________________________________________ ( _______________________)
Last name First name Middle initial Maiden name
2. Address
Home: _____________________________________________________________________________________________
Street City State ZIP code County
____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
3. SocialSecurityNumber
You must provide your Social Security number to the Board or Committee. Failure to do so may result in denial of
licensureorcerticationreactivation.
*SocialSecurityNumber: __________ -____________ -___________
*PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChild
SupportEnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardor
CommitteeisrequiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoardorCommitteeisalso
obligatedtoprovideyourSocialSecuritynumberto:
 a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing
compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;and
b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest.
4. Citizenship/ImmigrationStatus
FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualiedaliens.
Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. ChildSupport(You must answer a, b, c and d.)
Pleasecertify,underpenaltyofperjury,thefollowing:
a. Doyoucurrentlyhaveachild-supportobligation? Yes No
(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No
(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No
c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No
d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No
InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsa(1)throughdmayresultinadenial
oflicensureorcertication.Furthermore,anyfalsecerticationoftheabovemaysubjectyoutoapenalty,including,but
notlimitedto,immediaterevocationorsuspensionoflicensure.
 ___________________________________ ___________________________________ ________________________

Applicant’sname(pleaseprint) Applicant’ssignature Date
click to sign
signature
click to edit
6. Haveyoueverchangedyourname? Yes No
If“Yes,”pleasesubmitwiththisapplicationacopyofthemarriagecerticate,divorcedecreeorcourtorder.
7. Haveyoueverbeensummoned;arrested;takenintocustody;indicted;tried;chargedwith;admittedintopre-trialintervention
(P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicle
violationssuchasdrivingwhileimpairedorintoxicatedmustbe.)  Yes No
8. Haveyoueverbeenconvictedofanycrimeoroffenseunderanycircumstances?Thisincludes,butisnotlimitedto,aplea
ofguilty,nonvult,nolocontendere,nocontest,orandingofguiltbyajudgeorjury.  Yes No
If“Yes,”provideacopyofthejudgmentofconvictionandthereleasefromparoleorprobation.Pleaseprovideacomplete
explanation.(Attachadditionalsheetsofpapertothisapplication.)
9. Haveyoupreviouslyappliedforacosmetology/hairstyling,beautyculture,barbering,skincarespecialtyormanicuring
licenseinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
If“Yes,”whenandwhere?__________________________________________________________________________________
10.Doyoucurrentlyhold,orhaveyoueverheld,aprofessionaloroccupationallicenseorcerticateofanykindinNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
If“Yes,”foreachlicenseorcerticateheld,providethedate(s)heldandthenumber(s).Ifthelicensewasissuedundera
differentname,pleaseprovidethatname.
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
11. HaveyoueverheldatemporarylicenseorlimitedpermitinNewJersey,anyotherstate,theDistrictofColumbiaorinany
otherjurisdiction?  Yes No
If“Yes,”listthedateofissuanceandexpirationandthejurisdictionwherethetemporarylicenseorlimitedpermitwasgranted.
Dateofissuance_____________________ Expirationdate _____________________ Jurisdiction______________________
12. Haveyoueverbeencitedfordisciplinaryreasonsordeniedaprofessionaloroccupationallicenseorcerticateofanykind
inNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
13. Haveyoueverhadaprofessionaloroccupationallicenseorcerticateofanytypesuspended,revokedorsurrenderedin
NewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
14. Hasanyaction(includingtheassessmentofnesorotherpenalties)everbeentakenagainstyourprofessionaloroccupational
practicebyanyagencyorcerticationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
Yes No
15. Haveyoueverbeennamedasadefendantinanylitigationrelatedtothepracticeofcosmetology/hairstyling,beautyculture,
barbering,manicuringorskincarespecialtyorotherprofessionaloroccupationalpracticeinNewJersey,anyotherstate,
theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
16. Areyouawareofanyinvestigationpendingagainstaprofessionaloroccupationallicenseorcerticateissuedtoyoubyaprofessional
oroccupationalboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
Yes No
17. ArethereanycriminalchargesnowpendingagainstyouinNewJersey,anyotherstate,theDistrictofColumbiaorinany
otherjurisdiction? Yes No
18. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessional
oroccupationalgrouprelatedtothepracticeofcosmetology/hairstyling,beautyculture,barbering,manicuringorskincare
specialtyorotherprofessionaloroccupationalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinany
otherjurisdiction? Yes No
Ifthe answerto anyofthe abovequestions, numbers 12 through18, is“Yes,” providea complete explanation of the
circumstancesleadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
______________________________________________________________________________________________________________
Last
name F
irst
name Middleinitial
Experience acquired since your license became inactive in New Jersey.
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: _________________________ (include area code) Hours per week: ____________________
Your major responsibilities (use additional sheets of paper if necessary):
Employed from ____________________________ to _____________________________
Month Year Month Year
Immediate supervisor’s name: _____________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: _________________________ (include area code) Hours per week: ____________________
Your major responsibilities (use additional sheets of paper if necessary):
Employed from ____________________________ to _____________________________
Month Year Month Year
Immediate supervisor’s name: _____________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: _________________________ (include area code) Hours per week: ____________________
Your major responsibilities (use additional sheets of paper if necessary):
Employed from ____________________________ to _____________________________
Month Year Month Year
Immediate supervisor’s name: _____________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: _________________________ (include area code) Hours per week: ____________________
Your major responsibilities (use additional sheets of paper if necessary):
Employed from ____________________________ to _____________________________
Month Year Month Year
Immediate supervisor’s name: _____________________________________________________________________________
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: __________________________________________________
County of:________________________________________________
I, _______________________________________________________ , in making this application to the New Jersey State Board of
Cosmetology and Hairstyling for licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey
and the Rules of the New Jersey State Board of Cosmetology and Hairstyling, swear (or afrm) that I am the applicant and that
all information provided in connection with this application is true to the best of my knowledge and belief. I understand that
any omissions, inaccuracies or failure to make full disclosures may be deemed sufcient to deny licensure or certication or to
withhold renewal of or suspend or revoke a license or certicate issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:5B-1 et seq., together with the Rules and Regulations of the New Jersey
State Board of Cosmetology and Hairstyling, N.J.A.C. 13:28-1.1 et seq., and fully understand that in receiving licensure or
certication from the Board, I bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities
for the purpose of verifying my qualications for licensure or certication. I further authorize all institutions, employers,
agencies and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les
or records requested by the Board.
_________________________________________________
Signature of applicant
Sworn and subscribed to before me this _______
day of __________________________ , 20 ____
Month
_________________________________________
Name of Notary Public (please print)
_________________________________________
Signature of Notary Public
} ss.
Afx seal here
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Inactive Fees New Jersey Ofce of the Attorney (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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