Form DBPR COSMO11 "Individual Change of Status Transactions" - Florida

What Is Form DBPR COSMO11?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 29, 2012;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DBPR COSMO11 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR COSMO11 "Individual Change of Status Transactions" - Florida

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State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Individual Change of Status Transactions
Form # DBPR COSMO 11
TRANSACTION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
form to ensure faster processing.
TRANSACTION
TRANSACTION REQUIREMENTS
Complete Sections II and VI of this form.
Request Duplicate
Pay $25 fee (make check payable to the Department of Business and
License
Professional Regulation).
Submit police report, if applicable.
Complete Sections III and VI of this form.
Personal Name
Pay $25 fee (make check payable to the Department of Business and
Change
Professional Regulation).
with Issuance
Submit supporting legal documentation of name change (e.g. court
of Updated
documents showing name change, marriage license, divorce decree,
Licensee
etc.).
Complete Sections IV and VI of this form.
Personal Address
No Fee.
Change
Complete Sections IV and VI of this form.
Personal Address
Pay $25 fee (make check payable to the Department of Business and
Change with
Professional Regulation).
Issuance of
Updated License
Complete Sections V and VI of this form.
Set License to
Pay $5 fee if not within renewal period (make check payable to the
Inactive
Department of Business and Professional Regulation).
Complete Sections V and VI of this form.
Set License to
Pay $50 fee (make check payable to the Department of Business and
Active
Professional Regulation).
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, Fl 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. Application Instructions (by section)
a. Section I
i.
Check only the applicable transaction(s) you are seeking.
b. Sections II through V
i.
Fill out each section completely, as applicable.
ii.
If you are requesting a Name Change, you must submit supporting documentation (e.g.
marriage certificate, divorce decree)
c. Section VI
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
DBPR COSMO 11 Individual Change of Status Transactions
Incorporated by Rule: 61-35.011
May 29, 2012
1 of 3
State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Individual Change of Status Transactions
Form # DBPR COSMO 11
TRANSACTION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
form to ensure faster processing.
TRANSACTION
TRANSACTION REQUIREMENTS
Complete Sections II and VI of this form.
Request Duplicate
Pay $25 fee (make check payable to the Department of Business and
License
Professional Regulation).
Submit police report, if applicable.
Complete Sections III and VI of this form.
Personal Name
Pay $25 fee (make check payable to the Department of Business and
Change
Professional Regulation).
with Issuance
Submit supporting legal documentation of name change (e.g. court
of Updated
documents showing name change, marriage license, divorce decree,
Licensee
etc.).
Complete Sections IV and VI of this form.
Personal Address
No Fee.
Change
Complete Sections IV and VI of this form.
Personal Address
Pay $25 fee (make check payable to the Department of Business and
Change with
Professional Regulation).
Issuance of
Updated License
Complete Sections V and VI of this form.
Set License to
Pay $5 fee if not within renewal period (make check payable to the
Inactive
Department of Business and Professional Regulation).
Complete Sections V and VI of this form.
Set License to
Pay $50 fee (make check payable to the Department of Business and
Active
Professional Regulation).
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, Fl 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. Application Instructions (by section)
a. Section I
i.
Check only the applicable transaction(s) you are seeking.
b. Sections II through V
i.
Fill out each section completely, as applicable.
ii.
If you are requesting a Name Change, you must submit supporting documentation (e.g.
marriage certificate, divorce decree)
c. Section VI
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
DBPR COSMO 11 Individual Change of Status Transactions
Incorporated by Rule: 61-35.011
May 29, 2012
2 of 3
State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Individual Change of Status Transactions
Form # DBPR COSMO 11
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
For additional information see the Instructions at the beginning of this application.
Section I – Application Type
CHECK ONE OF THE TRANSACTION TYPES
(Use multiple forms if more than one transaction is applicable)
Duplicate License Request [8001]
Complete sections II and VI.
Personal Name Change with Issuance of Updated License [8001]
Complete sections III and VI.
Personal Address Change [9006]
Complete sections IV and VI.
Personal Address Change with Issuance of Updated License [8001]
Complete sections IV and VI.
Set License to Inactive [4020]
Complete sections V and VI.
Set License to Active from Inactive [3020]
Complete sections V and VI.
Name:
License Number:
Email Address:
Phone Number:
Section II – Request Duplicate License
DUPLICATE LICENSE INFORMATION
Type of License:
 Cosmetologist
 Facial Specialist
 Nail Specialist
 Full Specialist
 Hair Braider
 Hair Wrapper
 Body Wrapper
Please indicate reason for duplicate license request:
 Lost
 Destroyed
 Stolen – no charge (requires submission of police report)
 Change of address
Section III – Personal Name Change (provide supporting documentation)
PERSONAL NAME CHANGE INFORMATION
New Name
**NOTE – Your name on your license will appear as it is printed below***
*
DBPR COSMO 11 Individual Change of Status Transactions
Incorporated by Rule: 61-35.011
May 29, 2012
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Section IV – Personal Address Change
NEW PHYSICAL ADDRESS
Street Address
City
State
Zip Code (+4 Optional)
County
Country
NEW MAILING ADDRESS
Street Address
City
State
Zip Code (+4 Optional)
County
Country
Section V – Set License to Inactive/Active
LICENSEE INFORMATION
Set License to:
 Active
 Inactive
Section VI – Affirmation By Written Declaration
AFFIRMATION BY WRITTEN DECLARATION
I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I
understand that my signature on this written declaration has the same legal effect as an oath or
affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts
stated in it are true. I understand that falsification of any material information on this application
may result in criminal penalty or administrative action, including a fine, suspension or revocation
of the license.
Signature:
Date:
Print Name:
DBPR COSMO 11 Individual Change of Status Transactions
Incorporated by Rule: 61-35.011
May 29, 2012
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