Name of Applicant:          Level of Course:   

DOB:   Sex:     Marital Status:                 

Mailing Address:                 Ph #:  

E-mail Address:         Fax: #: 

Current Occupation:                                           Work #:  

Have you received Training in any of the following :

Medical Field        Makeup Artist       Electrolysis        Cosmetology  
Skin Care              None Related

What levels of these Trainings have you previously received


Educational Background:

High School Diploma            Year Graduated

College Diploma                   School Attended Major
 

Spouse's Name:   

Emergency Contact Name & #: 

Medical History: Please list any Diseases you may have or had in the past:


Please list any know allergies:

Are you presently taking any medications? If so, please list:

Month of Attendance: February March April May June 

Payment Information: Check Credit Card Other

I hereby represent that all if the information supplied above is true and correct. I understand that this information will form the basis of my application for Training by CBC. I agree to abide by the training curriculum and code of good ethics. I understand the Training is the basis for my ability to perform Permanent Cosmetics and does not allow me to do business without proper permits and licenses in the state in which I reside and practice. I understand the cost if the course is $3500.00, which includes a non- refundable deposit of $500.00.

I Agree with the above statement
I do not agree with the above statement