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 ________________________________________ Telephone # ______________
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, 214 Green Bay Rd., Thiensville, WI 53092.