Student Application

First Name

Last Name

Phone

Alternate Phone

Birth Date xx/xx/xxxx

Social Security Number

Email Address

Mailing Address

Apt/Suite

City

State/Province

Zip/Postal Code

Country

Gender Gender Male Female

Citizenship Citizenship U.S. Citizen Permanent Resident International

Do you want to apply for a Program or an Individual Class? Do you want to apply for a Program or an Individual Class? Program Individual Class(es)

Which Program do you want to Attend? Which Program do you want to Attend? Master Makeup Artistry Pro Master Makeup Artistry Production Makeup Artistry Fashion Makeup Artistry Skin Care

Which Class do You want to Attend? Which Class do You want to Attend? Basic Beauty Module Airbrushing Class Wedding & Event Class Character Class Special FX Courses

When Do You want to Start your Program? When Do You want to Start your Program? August 10, 2020 October 19, 2020 January 11, 2021 March 22, 2021 June 1, 2021 August 9, 2021 October 18, 2021

When do you want to attend a class?

Please Check Off the Following: Please Check Off the Following: I have a High School Diploma I have a G.E.D. or equivalent I will upload a picture of my document I do not have the above documents

Are you a Licensed Cosmetologist or Esthetician? Are you a Licensed Cosmetologist or Esthetician? Yes No

Please check (Statistical use only for State Agencies) Please check (Statistical use only for State Agencies) American Indian Caucasion Black Asian or Pacific Islander Hispanic Other

Foreign Students Only- All applicants who enter the U.S. on a student visa must complete the following questions about financial support. What is your source of financial support (SELECT ONE): Foreign Students Only- All applicants who enter the U.S. on a student visa must complete the following questions about financial support. What is your source of financial support (SELECT ONE): Self Family Member Parent Friend

In order to apply, students must submit a $100 non-refundable registration fee. Select your payment method: In order to apply, students must submit a $100 non-refundable registration fee. Select your payment method: Credit Card Will Mail Check Bank Transfer Other

Which Credit Card? Which Credit Card? Mastercard Visa

Credit Card Number

Name on the Card

Expiration Date xx/xx

Security Code (CVV)

Credit Card Authorization Credit Card Authorization I authorize Cosmix to charge my credit card

Routing Number

Bank Account Number

Account Holder's Name

Signature