Application Form
Please complete this form and mail or bring to the school the along with the following information:

A copy of high School Diploma or G.E.D., Birth Certificate, Photo I.D., and $25.00 administrative fee.

Mailing Address:
Premier College of Cosmetology
4043 S. Michigan Street
South Bend, IN 46614
Tel: 574-299-1745 or 574-299-1795

APPLICATION FOR ENROLLMENT

I hereby apply for acceptance in the program of study checked below:

  __ Cosmetology  __ Nail Technology   

For the month and year of:________,____.  Full Time __ Part Time __

Personal Information:

Name _________________________________

S.S # _______________________________

Address _________________________________

Phone ______________________________

Date of Birth ____________________________

Have you ever been convicted of a felony or misdemeanors in the last five years?
If Yes, Please explain: ________________________________________________________
__________________________________________________________________________
Are you employed now? ______
May we contact your employer? _____
Have you ever applied here before? ______ When? ________

Education
Name _________________________________________
Year Graduated _________________________________
High School ____________________________________
College ________________________________________
Other _________________________________________

APPLICANT INFORMATION

Name __________________________________________________________________
          Last                   First                              Middle Initial           Maiden
Address ____________________________________ City _____________  State ___

Previous ____________________________________ City ______________State ___

S/S# ______________________

Date of Birth ___/___/___ Age is not a factor in my decision, but for identification purpose only.

Driver's License # ______________________________
Driver's License State ________

EDUCATIONAL BACKGROUND
College Attended:
___________________________________City ______________ State ___ From ___ To __
High School Attended:
___________________________________City ______________ State ___ From ___ To __
Other School Attended:
___________________________________City ______________ State ___ From ___ To __
Degree(s) earned:
___________________________________City ______________ State ___ From ___ To __

List any names used at last school _________________________________________

List all convictions including traffic and criminal		Previous City & State of convictions
Year	Offense	City	State

I have been informed that a consumer report maybe obtained on me for enrollment purposes. I hereby authorize the release to Human Resource Profile Inc., no independent contract agency of information held by any parties regarding my previous employment, my criminal history record and/or record of convictions in state and local files for violations of any federal. State, local statues of ordinances, military records, my credit history, workers compensation history driving record and scholastic records. I hereby release said persons, schools. Companies. Employment agencies, court and law enforcement authorities from any damage what so ever issuing this information. I further understand this information may be reviewed periodically by Human Resource Profile Inc., and reported to my prospective employer.

I hereby acknowledge that Human Resource Profile Inc. cannot vouch for or guarantee the accuracy of information provided by third parties. Accordingly. I release Human Resource Profile Inc., its agents and/or prospective employees from any and all liability regarding any background information and authorize Human Resource Profile Inc. to release any and all information to my prospective employer.

 Reference: List one FORMER EMPLOYER

Dates________________
Name/Address __________________________________________
Position _______________________________________________
Reason for leaving ________________________________________

Personal REFERENCE

Name ________________________________________________
Address ______________________________________________
Phone ________________________________________________
Years Acquainted________________________________________

Do you have any physical limitations that will prevent you from performing your duties here at Premier? Yes   No

If yes, please explain_______________________________________________.

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that, if enrolled statements on this applications shall be grounds for dismissal. I authorize investigation of all statements contained here and the references listed above to give you all information they may have, personal or otherwise, and release parties from all liability for any damage that ma y result from furnishing such information to you.

I understand there is a $25.00 non-refundable application fee due at this time. I understand and agree that if enrolled at Premier, my enrollment is for no definite period and may be determined at any time without prior notice.

Signature ______________________________ Date _________________________

EMPLOYER PROFILE NOTIFICATION

Please read before completing and signing the applicant profile.

I have been informed that a consumer report may be obtained on me for enrollment purpose. I hereby authorize this procurement of this report by human resources profile and for my prospective employer.

Signature ______________________________ Date _________________________