Manicurist License Renewal Application Form

Full Legal Name

First NameMiddle NameLast Name

Business/Professional Name (if applicable)

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Current License Number

Current License Expiration Date

Date

License Type or Category

Renewal Cycle / Term

Renewal Status

Current employment status

Workplace or salon name

Workplace address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Primary service location or business mailing address (if different)

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Completed Training Hours

Training Provider or Course Name

Course Completion Date

Date

Requirements Confirmed

Upload Certificates or Proof of Completion

Applicant Signature

Supporting Documents