Enrollment Application GENERAL INFORMATION Full Name: Marital Status:Please SelectDivorcedMarried or domestic partnershipSeparatedSingle, never marriedWidowed Date Of Birth: Social Security Number: Ethnicity:Please SelectAsian / Pacific IslanderBlack or African AmericanHispanic or LatinoNative American or American IndianOtherWhite Sex: MaleFemale Street Address: Apt.#: City: State: Zip Code: Home Phone: Cell Phone: Other Phone: Driver's License or State ID Number: Expiration Date: Email Address: Are you a Veteran? YesNo If Yes, please provide your service #: Are you Employed? YesNo If Yes, please provide your place of employment: Have you ever been convicted? YesNo If Yes, please explain: Do you suffer from any chronic diseases like Cystic Fybrosis? YesNo If Yes, please explain: EDUCATION Do you have a High School Diploma or GED? YesNo If Yes, when did you graduate: High School Attended: City/State: Street Address: Zip Code: If you are expecting to graduate from high school or receive a GED, what is your graduation date? COLLEGE PROGRAM Course Of Interest: Please SelectClass A BarberCosmetology Operator to Class A BarberStudent Specialty Services Anticipated Schedule: Full TimePart Time REFERENCES Please provide a list of three references from individuals other than immediate family members. Name: Relationship: Phone Number: Years Known: Name: Relationship: Phone Number: Years Known: Name: Relationship: Phone Number: Years Known: EMERGENCY CONTACTS Name: Name: Phone Number: Phone Number: SIGNATURE Applicant Signature: Date: Δ