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Enrollment Application

10134 Colvin Run Rd . Suite c . Great Falls Va 22066 – 703.624.6666

Programs Of Interest: Cosmetology

First Name

Middle Name

Last Name

Home Number

Emergency Contact Number

Date of Birth:

Social Security:

Cancellation Policy: This contract contains entire agreement between the student and the academy relating to this contact. Any changes to this contact must be in writing and must be signed by all parties

NO VERBAL CHANGES ARE BINDING:

Full time Student:

Yes No

Part time student:

Yes No

High School graduate

Yes No

Circle last grade completed 8, 9, 10, 11, 12 GED :

Year:

High school name:

Citizenship:

United State:

Yes No

Alien/PRC/Passport/State Driver Liense

Payment Structure:

Private Pay

Grant/Loan

D.P.A :

Other:

From The Prospective Student: I agree that all the above information is true and correct, failure to company will result in the immediate rejection of this application.

Signature:

Date:

Enrollment Application

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