New Jersey Office of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Cosmetology and Hairstyling
124 Halsey Street, 6th Floor, P.O. Box 45003
Newark, New Jersey 07101
(973) 504-6400
Change of Name/Address Form
Please print clearly.
Name: ______________________________________________________________________
License number: ______________________________________________________________
Address: ____________________________________________________________________
Street
____________________________________________________________________________
CityStateZIP code
New address: ________________________________________________________________
Street
____________________________________________________________________________
CityStateZIP code
New name: __________________________________________________________________
Signature: ___________________________________________________________________
Please Note: You must submit certiied or sealed legal documentation with this form to request a name change with the Board Ofice.
Please Fax or Mail to: New Jersey State Board of Cosmetology and Hairstyling P.O. Box 45003
Newark, NJ 07101
Fax number: (973) 504-6477