School of Esthetics Application Form
Please print this form and fill out completely.
Applicant Name: ___________________________________________
Address: __________________________________________________
City: _____________________________ State: _________ Zip: __________
Phone: ______________________________ Alt. # _____________________
E-mail address: _____________________________________
Personal History:
Social Security # ________________________ Date of Birth: _____________
Age: _____ Sex: ______ Marital Status: Single____ Married ____ Other ____
Spouses Name: _______________________ Number of Dependents: ______
Education: (Circle last grade completed)
8 9 10 11 12
13 14 15 16
Degree: _____
Indicate if any of these apply:
High School Diploma ___ Equivalency Diploma ___College ___
How is your general health? ___________________________
Do you have any physical disabilities? _________
Are you under a physicians care? Yes _____ No ______
Are you on any medications or substances? __________
If yes, please list______________________________________________
Father's Name: _____________________ Telephone # _________________
Address: ______________________________________________________
City/State/ Zip Code: _____________________________________________
Mother's Name: ____________________ Telephone # __________________
Address: ______________________________________________________
City/State/ Zip Code: _____________________________________________
Name of nearest relative _______________ Telephone # ________________
Give two (2) references that we may contact by letter or telephone:
1. Name _______________________________ Title __________
Relationship ____________________________________
Address ________________________________________
Telephone # ____________________________
2. Name _______________________________ Title __________Relationship ____________________________________
Address ________________________________________
General Information:
How were you referred to Mequon/Thiensville School of Esthetics?
_____________________________________________________________
Why do you want to attend a school of esthetics?
_____________________________________________________________
What aspects of skin care interest you? Rate your interests from 1 (most) to 8 (least)
Facials _____ Makeup _____ Nutritional Therapy _____ Massage _____
Waxing _____ Body Treatments _____ Equipment Usage _____
What do you expect your future salary to be as an Esthetician?
Upon graduation: $________ Two (2) years after graduation: $__________
How did you become interested in the field of esthetics?
____________________________________________________________
What are your goals in the field of esthetics?
____________________________________________________________
What are your expectations of this program?
____________________________________________________________
My signature certifies that the above information is correct.
_________________________________ _________________________
Applicant's Signature Date
_________________________________ _________________________
Interviewer's Signature Date
Please send completed application form
with enrollment and registration fee of $100.00 to:
Mequon Thiensville School of Esthetics, 11135 N. Wauwatosa Road, Mequon, WI 53097.