Transcription of HEALTH LICENSING OFFICE Board of Cosmetology
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HEALTH LICENSING OFFICE Board of Cosmetology
Application continued on the next page HEALTH LICENSING OFFICE Board of Cosmetology 1430 Tandem Ave. NE, Suite 180, Salem, OR 97301-2192 Phone: 503-378-8667 | Fax: 503-370-9004 | Email: Cosmetology FACILITY LICENSE APPLICATION The holder of a Facility license must be a natural person 1. Applicant Information Applicant (Responsible Party) Name: Date of Birth Social Security Number (REQUIRED) Residential Physical Address (REQUIRED) City State Zip Home Phone: Cell Phone Email Address Name of Facility Business Telephone Assumed Business Name (As filed with Secretary of State, Corporation Division) Registry Number (Secretary of State, Corporation Division) Facility Phy
Application continued on the next page . HEALTH LICENSING OFFICE . Board of Cosmetology . 1430 Tandem Ave. NE, Suite 180, Salem, OR 97301-2192 Phone: 503-378-8667 | Fax: 503-370-9004
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