New Jersey Ofce 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
Verication of State License
Request Form
All originals are sent directly to the receiving state.
Please print clearly or type. You may duplicate this form if necessary.
Date of birth: _______________________ Date : ____________________________
A nonrefundable fee of $25.00 in the form of a check or money order made out to the State of New Jersey, must be submitted with
this form. (Licensees should understand that if the application ling fee is paid with a personal check, and the check is returned
by the bank due to insufcient funds, the next step in the verication process will be delayed until the fee is paid.)
Name ______________________________________________________________________________________________________
Last name First name Middle initial
License No. 32W__________________________________ Date issued __________________ Expiration date ________________
Address ____________________________________________________________________________________________________
Street or P.O. Box City State ZIP code
Telephone No. ___________________________ (include area code)
School of Cosmetology attended ________________________________________________________________________________
State to receive Verication of State License _______________________________________________________________________
State Board to receive Verication of State License __________________________________________________________________
Comments
I certify that the statements contained herein are true based upon ofcial records that I reviewed.
______________________________________ ______________________________________ ____________________
Print name Signature Date
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signature
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