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PERSONAL LICENSE RENEWAL
Cashiering
Use Only:
2020
Entity #
Receipt #
Amount
$
INSTRUCTIONS
Mail this form and a check or money order (do not send cash) (fee for each license type renewal below) to the address above
payable to the Board of Barbering and Cosmetology (incomplete forms will not be processed). You can also renew your
license online at www.barbercosmo.ca.gov .
SECTION A: LICENSEE INFORMATION
LICENSE TYPE AND FEE:
If postmarked If postmarked
on or before after
expiration date. expiration date.
Barber (1001) $50.00 $75.00*
Cosmetologist (1002) $50.00 $75.00*
Electrologist (1003) $50.00 $75.00*
Esthetician (1004) $50.00 $75.00*
Manicurist (1005) $50.00 $75.00*
*Based on a 2 year cycle.
LICENSE NUMBER:
Letter(s):
Numbers:
Last Name (print clearly)
Middle Name
If your name has changed, attach completed Change of Name form with this renewal*.
Last 4 digits of your Social Security Number or Individual Taxpayer Identification Number
Date of Birth
- -
Month Day Year
If your address has changed, please fill out the information below:
Previous Street Address
City
State
Zip Code
Current Street Address
City
State
Zip Code
Telephone Number
- -
E-mail Address
SECTION B: BACKGROUND INFORMATION
1. Have you served, or are you currently serving, in the military? No Yes
2. (Optional) What is your spoken and written language preference? _____________________________________________
SECTION C: APPLICANT CERTIFICATION
I certify that I have read and understand the information, Know Your Workers’ Rights, provided by the California Board of
Barbering and Cosmetology. I certify that I have read and understand the laws and regulations pertaining to this profession in
California. 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.
Signature
Date
*All forms and applications can be found on the Board’s
website at www.barbercosmo.ca.gov under “FORMS/PUBS”.
Please email the Board at barbercosmo@dca.ca.gov with any questions regarding this renewal.
(Revised July 2017) Page 1 of 2
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY ● GAVIN NEWSOM, GOVERNOR
DEPARTMENT OF CONSUMER AFFAIRS ● BOARD OF BARBERING AND COSMETOLOGY
P.O. Box 944226, Sacramento, CA 94244-2260
Phone: (800) 952-5210 Email: barbercosmo@dca.ca.gov
Website: www.barbercosmo.ca.gov
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INFORMATION COLLECTION, ACCESS AND DISCLOSURE
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 fax
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) OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER (ITIN)
DISCLOSURE
Disclosure of your SSN or ITIN 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)] authorizes collection of your SSN or ITIN. Your SSN or ITIN 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 SSN or ITIN, you will be reported to the Franchise Tax Board, which may
assess a $100 penalty against you.
TAXPAYER INFORMATION
Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board may share taxpayer information with
the board. You are obligated to pay your state tax obligation and your license may be suspended if the state tax obligation is
not paid.
(Revised January 2015)
Page 2 of 2
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY ● GAVIN NEWSOM, GOVERNOR
DEPARTMENT OF CONSUMER AFFAIRS ● BOARD OF BARBERING AND COSMETOLOGY
P.O. Box 944226, Sacramento, CA 94244-2260
Phone: (800) 952-5210 Email: barbercosmo@dca.ca.gov
Website: www.barbercosmo.ca.gov
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