STUDENT APPLICATION

Note: If the item is not applicable, kindly input "N/A" in the respective field.

Today's Date *

Program to attend *

COSMETOLOGY

ESTHETICS

First Name *

Last Name *

Maiden *

Home Address *

City *

State *

Postal code *

Mailing Address (if different from above)

City

State

Postal code

Phone *

Email *

Highest Level of Education Completed *

School Attended *

Sex *

Male

Female

Date of birth *

City and State of Birth *

Social Security Number *

Driver's License Number *

Current Occupation *

Number of Years *

Number of Months *

Employer *

Supervisor Name *

Employer Phone *

Employer Email Address *

Name and Phone Number of Closest Living Relative *

Have you ever been convicted of a crime? *

Yes

If yes, please explain

Have you ever been disciplined by the SC Board of Cosmetology or a similar Board in our outside of SC? *

Yes

If so, why?

Are you looking to be a cosmetologist, or a Esthetician, or both? *

Why do you want to be a Cosmetologist/Esthetician? *