CONTACT INFORMATION UPDATE FORM FOR CERTIFIED INDIVIDUALS

If you are simultaneously submitting a renewal application, then you don't need to also use this form - you can do it on the renwal application. This form is most appropriate to update your contact information in between periods of renewal.
Name
Prev Name if name change
Mailing Address
Contact Phone #
Email address (REQUIRED)
Type of Certification(s)
Confirm Email
Check all that apply (we confirm them)
CLO-A     Certified Aesthetic Laser Operator
CLHRS -  Certified Laser Hair Removal Specialist
CLHRS -  CLHRS Supervisor
CLSO-M - Certified Medical Laser Safety Officer
CLRT -     Certified Laser Repair Technician
Comments:
Please list address exactly as it would printed on a mailing envelope, mailed from the U.S.
Click for new image
Please enter the txt into the box