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AA0004374711 2

Jessica A. Miller is applying for the renewal of her cosmetology license, with her application currently pending review as of December 21, 2022. She has completed the application fee and answered legal questions affirmatively regarding her professional history and disciplinary actions. Additionally, she acknowledges her duty to self-report any disciplinary conduct or criminal activity as required by Pennsylvania law.

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11 views3 pages

AA0004374711 2

Jessica A. Miller is applying for the renewal of her cosmetology license, with her application currently pending review as of December 21, 2022. She has completed the application fee and answered legal questions affirmatively regarding her professional history and disciplinary actions. Additionally, she acknowledges her duty to self-report any disciplinary conduct or criminal activity as required by Pennsylvania law.

Uploaded by

vxcjj6rxym
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Cosmetology- Cosmetologist- Examination

Renewal (CO256841)
AA0004374711

BUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS


P. O. Box 2649
Harrisburg, PA 17105-2649
APPLICANT INFORMATION

PERSONAL INFORMATION
Last Name MILLER First Name JESSICA
Middle Name A Suffix

Full Name JESSICA A MILLER


SSN 3791 Date Of Birth 04/14/1980 Age 42 Gender FEMALE
ADDRESS DETAILS
Street Address 410 SOUTH MAIN STREET APT. B. BANGOR, PA 18013
City/State/Zip Bangor PA 18013
County Northampton Country United States
CONTACT DETAILS
Phone number 5702364317 Mobile Phone number

Primary Email Address jamiller2968@yahoo.com Secondary Email Address

CHECKLIST ITEMS
Checklist name Status Submitted Date Expiration Date

Application Pending Review 12/21/2022


Application Fee Completed 12/21/2022
LEGAL QUESTIONS
Questions Answer Document File Name
Uploaded

1 Are you submitting a name change with this renewal? N No


2 First Name No
3 Middle Name No
4 Last Name No
5 No
You must submit a copy of a legal document verifying the name
(s). The following are acceptable name change verification
documents:
(1) A birth certificate.
(2) A marriage certificate (not a marriage license).
(3) Divorce decree.
(4) An official name change document issued by a court.
(5) A passport.
(6) A social security card.
(7) A Pennsylvania driver’s license or non-driver ID card.
(8) A driver’s license or official non-driver ID card issued by
another state that complies with the federal REAL ID Act
requirements (signified with a star on the front)

6 With the exception of the one you are currently renewing, do you N No
hold, or have you ever held, a license, certificate, permit,
registration or other authorization to practice a profession or
occupation in any state or jurisdiction?
7 No
Please provide the profession and state or jurisdiction.

8 Since your initial application or last renewal, whichever is later, N No


have you had disciplinary action taken against a professional or
occupational license, certificate, permit, registration or other
authorization to practice a profession or occupation issued to you
in any state or jurisdiction or have you agreed to voluntary
surrender in lieu of discipline?
9 Do you currently have any disciplinary charges pending against N No
your professional or occupational license, certificate, permit or
registration in any state or jurisdiction?
10 Since your initial application or last renewal, whichever is later, N No
have you withdrawn an application for a professional or
occupational license, certificate, permit or registration, had an
application denied or refused, or for disciplinary reasons agreed
not to apply or reapply for a professional or occupational license,
certificate, permit or registration in any state or jurisdiction?
PA VETERANS REGISTRY
Questions Answer

1 Have you served in the U.S. Armed Forces? N


2 Thank you for your service. Would you like to register with the PA Veterans Registry? The PA
Veterans Registry provides veterans with information about federal, state and local benefits,
programs and services that are available to Pennsylvania veterans and links veterans with
resources that can provide assistance. Registration is quick and easy, and provides the
Department of Military and Veterans Affairs (DMVA) with a way to contact you regarding the
benefits and services you may be eligible for. If you check “Yes,” you will receive an email with
instructions to assist you in registering.
ACKNOWLEDGEMENT OF DUTY TO SELF-REPORT DISCIPLINARY CONDUCT AND CERTAIN CRIMINAL
ACTIVITY

I hereby acknowledge that in addition to any existing reporting requirement required by a specific board
or commission, I am REQUIRED pursuant to Act 6 of 2018 to NOTIFY the Bureau of Professional and
Occupational Affairs WITHIN 30 DAYS of the occurrence of any of the following:
(1) A disciplinary action taken against me by a licensing board or agency in another jurisdiction;
(2) A finding or verdict of guilt, an admission of guilt, a plea of nolo contendere, probation without verdict, a
disposition in lieu of trial or an Accelerated Rehabilitative Disposition (ARD) of any felony or misdemeanor
offense in a criminal proceeding. I further acknowledge that failure to comply with these mandatory
reporting requirements may subject me to disciplinary action by the Board. I acknowledge my
understanding that to self-report a disciplinary action or criminal matter as set forth above, I may log in to the
Pennsylvania Licensing System (PALS) at www.pals.pa.gov and select “Mandatory Reporting by Licensee”
under the heading “Your Licenses.”

( 12/21/2022 10:35:30 )
CONFIRMATION

Any fees paid are non refundable. ( 12/21/2022 10:35:30 )

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