Admissions Application Form

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Personal Information

Legal Name*

First Middle Last

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birthdate

Sex

Male
Female

Day Phone

Evening Phone

SSN

Social Security Numbers

Country of Birth

Country of Citizenship

How did you hear about us?

Emergency Contact Information

Emergency Contact

Name of Emergency Contact

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day Phone

Evening Phone

References (2)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Education

High School

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Did you graduate?

Yes
No

What year did you graduate?

How many years did you complete?

Have you attended college/university?

Yes
No

College

What college or university did you attend?

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Did you graduate?

Yes
No

What year did you graduate?

How many years did you complete?

Course of Study

Degree

Have you attended a vocational school?

Yes
No

Vocational School

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Did you graduate?

Yes
No

What year did you graduate?

How many years did you complete?

Course of Study

Degree/Certificate

Program

Esthetics
Master Esthetics
Esthetics / Master Esthetics Instructor

Start Date

What is the Start Date of your desired program?

Licensure And Certification

Have you ever cancelled enrollment in or been terminated from an educational or training program?

No
Yes

Please explain

Have you ever been licensed or certified?

Yes
No

By what organization?

From what organization did you receive your license or certification?

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Has your license or certification ever been revoked or suspended?

No
Yes

Please explain, including current litigation, if any.

Have you ever been convicted of a felony or misdemeanor?

No
Yes

Please explain, including current litigation, if any.

Health

Please explain any care you have received from a medical doctor, holistic practitioner, psychotherapist or counselor.

Please describe your physical, emotional and mental health.

Please explain any hospitalizations, institutionalizations or prescription medications for illness.

Excluding antibodies, please detail any prescription medications taken in the last 2 years.

Do you have or have you had any communicable diseases or conditions within the past 2 years that affect giving or receiving esthetic services?

Yes
No

Please describe any communicable diseases or conditions within the past 2 years that affect giving or receiving esthetic services.

Do you have any history of substance abuse?

No
Yes

Please describe any substance abuse, including recovery or rehab programs and specific dates of abuse and (ongoing?) recovery:

Supporting Documents

Brief Biological Sketch

Brief description of yourself from a “Best-Friend” perspective

Recent Photo

Passport Picture with white background

Accepted file types: jpg, png, pdf, Max. file size: 100 MB.

Your High School Diploma, GED and/or College Transcripts

Please scan a copy or copies of your documents and upload here.

Drop files here or

Max. file size: 512 MB.

Agreement*

I have completed this application to the best of my knowledge and state that the information I have given is true and correct.
I furthermore agree to comply with the institute’s policy that I will not attend classes or perform sessions under the influence of drugs or alcohol.

I agree to these statements.

Registration Fee*

The registration fee must be paid in full before this admissions application can be processed.

I will provide the $50 Registration Fee.

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