Form DBPR COSMO 9 Application for Continuing Education Course Approval or Renewal - Florida

Form DBPR COSMO9 or the "Application For Continuing Education Course Approval Or Renewal" is a form issued by the Florida Department of Business & Professional Regulation.

Download a PDF version of the Form DBPR COSMO9 down below or find it on the Florida Department of Business & Professional Regulation Forms website.

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State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Application for Continuing Education Course Approval or Renewal
Form # DBPR COSMO 9
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
 Complete all sections of this application.
 No fee is required.
 Submit a course outline, specifying subjects, major topics, and subtopics
to be covered in the course. Each subject must also include a narrative
summary.
 Submit a sample certificate of completion for the course.
Continuing Education
 Submit a list of all reference and source materials for the course.
Course Approval
 Submit a copy of the evaluation forms to assess the learning experience,
instructional methods, and course materials.
 List the instructors for each course and attach a resume for each
instructor even if previously approved for another course.
 Submit at least one complete copy of the course in its final form, as it will
be presented to the licensee, if approved.
 Record Keeping: Attendance records must be maintained for a
minimum of 4 years. Attendance records and course completion
information for all course participants must be provided to the
Department in a specified format acceptable to the Department and
within an agreed upon timeframe. These records must be made
available to the Department upon request.
 Complete all sections of this application.
 No fee is required.
Submit a course outline, specifying subjects, major topics, and subtopics
to be covered in the course. Each subject must also include a narrative
summary.
 Submit a sample certificate of completion for the course.
Continuing Education
 Submit a list of all reference and source materials for the course.
Course Renewal
 Submit a copy of the evaluation forms to assess the learning experience,
instructional methods, and course materials.
 List the instructors for each course and attach a resume for each
instructor even if previously approved for another course.
 Submit at least one complete copy of the course in its final form, as it will
be presented to the licensee, if approved.
 Record Keeping: Attendance records must be maintained for a
minimum of 4 years. Attendance records and course completion
information for all course participants must be provided to the
Department in a specified format acceptable to the Department and
within an agreed upon timeframe. These records must be made
available to the Department upon request.
Please mail your completed application, documentation to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, Fl 32399-0780
DBPR COSMO 9 Application for Continuing Education Course Approval/Renewal
Incorporated by Rule: 61-35.011 2013 Sept.
1 of 5
State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Application for Continuing Education Course Approval or Renewal
Form # DBPR COSMO 9
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
 Complete all sections of this application.
 No fee is required.
 Submit a course outline, specifying subjects, major topics, and subtopics
to be covered in the course. Each subject must also include a narrative
summary.
 Submit a sample certificate of completion for the course.
Continuing Education
 Submit a list of all reference and source materials for the course.
Course Approval
 Submit a copy of the evaluation forms to assess the learning experience,
instructional methods, and course materials.
 List the instructors for each course and attach a resume for each
instructor even if previously approved for another course.
 Submit at least one complete copy of the course in its final form, as it will
be presented to the licensee, if approved.
 Record Keeping: Attendance records must be maintained for a
minimum of 4 years. Attendance records and course completion
information for all course participants must be provided to the
Department in a specified format acceptable to the Department and
within an agreed upon timeframe. These records must be made
available to the Department upon request.
 Complete all sections of this application.
 No fee is required.
Submit a course outline, specifying subjects, major topics, and subtopics
to be covered in the course. Each subject must also include a narrative
summary.
 Submit a sample certificate of completion for the course.
Continuing Education
 Submit a list of all reference and source materials for the course.
Course Renewal
 Submit a copy of the evaluation forms to assess the learning experience,
instructional methods, and course materials.
 List the instructors for each course and attach a resume for each
instructor even if previously approved for another course.
 Submit at least one complete copy of the course in its final form, as it will
be presented to the licensee, if approved.
 Record Keeping: Attendance records must be maintained for a
minimum of 4 years. Attendance records and course completion
information for all course participants must be provided to the
Department in a specified format acceptable to the Department and
within an agreed upon timeframe. These records must be made
available to the Department upon request.
Please mail your completed application, documentation to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, Fl 32399-0780
DBPR COSMO 9 Application for Continuing Education Course Approval/Renewal
Incorporated by Rule: 61-35.011 2013 Sept.
2 of 5
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. General Requirements for Cosmetology Continuing Education Course Application
a. All portions of the application must be completed.
b. Continuing education providers must submit a sample course completion certificate with the
application. The sample course completion certificate must include the provider’s name, the
provider’s approval number, the licensee’s name, the licensee’s license number, the
approved course title, the course approval number, the course completion date, and the
number of approved continuing education credit hours awarded in each subject area covered
by the course.
c. Continuing education course applications must include course detail. Course detail includes:
i.
Course Outline: Attach a course outline specifying subjects, major topics, and subtopics
to be covered in the course. Each subject must also include a narrative summary.
ii.
Reference and Source Materials: Include a list of all reference and source materials,
along with their publication date(s), for the course.
iii.
Course Evaluation: Attach a copy of the evaluation forms used to assess the learning
experience, instructional methods, and course materials.
iv.
Instructors: List the instructors for each course, and attach a resume for each instructor
even if previously approved for another course. Instructors must possess sufficient skills
and knowledge in the subject areas being taught.
v.
Record Keeping: Attendance records must be maintained for a minimum of four years.
Attendance records and course completion information for all course participants must be
provided to the Department in a specified format acceptable to the Department and within
an agreed upon timeframe. These records must be made available to the Department
upon request.
d. Fee: No fees.
e. At least one complete copy of the course in its final form, as it will be presented to the
licensee, if approved, must be submitted.
2. Application Instructions (by section)
a. Section I
i.
Check only one of the application types.
ii.
Continuing Education Course Approval
(1)
Select this application type if you are applying for an initial approval of a
continuing education course.
iii.
Continuing Education Course Renewal
(1)
Select this application type if you are applying to have a continuing education
course approval renewed and there have been no changes to the course since
its initial approval.
(2)
If there have been any changes to the course, other than the instructors, you
must select “Continuing Education Course Approval” as the application type and
submit the supporting documentation required of an initial course approval.
b. Sections II
i.
Fill out each section completely.
ii.
Each applicant must provide their name, company or organization name, and their
provider approval number.
iii.
Applicants seeking to renew a course approval must also provide their current course
approval number.
c. Section III
i.
Applicants must provide the course title. The title you choose must adequately define the
content of the course. If you are applying to approve more than one course, please
complete additional applications as necessary.
ii.
Indicate which subject areas will be covered in the continuing education course and the
number of credit hours assigned to each subject area.
iii.
Indicate how the course will be provided to the student by checking the appropriate box.
A course provider may offer multiple methods of instruction for the course.
d. Section IV
i.
Please read and sign the affirmation by written declaration.
DBPR COSMO 9 Application for Continuing Education Course Approval/Renewal
Incorporated by Rule: 61-35.011 2013 Sept.
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ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
3. Other Information
a. Continuing education course providers shall not advertise a course as approved for
continuing education credit from the Board of Cosmetology until the course has been
approved by the board and a course number has been assigned.
b. Providers should supply all students with a course completion certificate upon completion of
the course.
c. Approved course numbers and course titles should be used in all advertisements.
d. Any substantive changes regarding the provider’s application information must be filed with
the department within thirty days of the change.
e. Provider approval is valid until May 31 of odd-numbered years and must be renewed.
Providers are responsible for renewing all courses prior to the course expiration date.
f.
Providers must work with licensees to resolve reporting conflicts.
g. Course approval is valid for two years from the date of board approval. Providers must
reapply for course renewal every two years.
Refer to Rule 61G5-32.001, Florida Administrative Code, for additional information regarding
provider and course requirements.
DBPR COSMO 9 Application for Continuing Education Course Approval/Renewal
Incorporated by Rule: 61-35.011 2013 Sept.
4 of 5
State of Florida
Department of Business and Professional Regulation
Board of Cosmetology
Application for Continuing Education Course Approval or Renewal
Form # DBPR COSMO 9
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 APPLICATION TYPES
Continuing Education Course Approval [0512/1030]
Continuing Education Course Renewal [0512/2020]
Section II – Applicant Information- Provider
PROVIDER INFORMATION
Last/Surname (Provider)
First
Middle
Suffix
Company/Organization Name
Provider Approval Number
Course Approval # (If renewal)
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
Contact Name:
Primary Phone Number
Primary E-Mail Address
BUSINESS LOCATION ADDRESS
Street Address
City
State
Zip Code
County (if Florida address)
Country
ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number
Fax Number
Alternate E-Mail Address
DBPR COSMO 9 Application for Continuing Education Course Approval/Renewal
Incorporated by Rule: 61-35.011 2013 Sept.
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Section III – Course Information
COURSE DATA
Course Title:
Subject Area (please check all that apply)
Credit Hours
HIV/AIDS and Other Communicable Diseases
Sanitation and Sterilization
Occupational Safety and Health Administration
Regulations
Workers’ Compensation Issues
State and Federal Laws and Rules
Chemical Makeup
Environmental Issues
Elective (title of elective course)
______________________
Total Course Hours
Methods of Instruction (check only one method):
 Live Study Group/Cosmetology Conference/Trade Show
 Distance/Online (Internet)
 Correspondence (Home Study/Video)
Section IV – 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 9 Application for Continuing Education Course Approval/Renewal
Incorporated by Rule: 61-35.011 2013 Sept.

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