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Zip Code
Phone
Date of Birth
City and State of birth
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Place of Employment (if applicable):
Employer Phone:

How did you hear about Academy Di Capelli?

Beauty Salon/Operator Former Student/Alumni Yellow Pages Coupon Book Website Newspaper High school reply card Other

Tuition to be paid by:

Cash Check Installment Plan Financial aid - SML Credit Card

Grade Completed
When can you start training? (mm/dd/yy)

I would like to enroll in the following courses (check all that apply)

Full Cosmetology arts and sciences Esthetic Skin Care

I would like to conduct my training as a...

Full time student Part time day student Part time night student

Referred by (student's name)

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