First Name *	Last Name *
Street Address *	Suite / Appt#
City *	State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code *	Phone Number *
Email Address *	Date of Birth (month /day/ year) *
Day / Evening Class * FT (Days) PT (Evenings)	U.S. Resident (Yes / No) * Yes No

I am applying for: * Massage Therapy Program Aesthetics Program Nail Technology Program Continuing Education

Education level completed: *    High School GED College Still in School

I would like to start on or around: * January February March April May June July August September October November December 2007 2008 2009 2010 2011 2012

Current Employment: (If applicable)
Employer Name	Employer Phone Number
Employer Address	Contact Person
Position Held	Full Time/Part Time Full Time Part Time
Please enter a brief summary about yourself including why you are interested in a career in Massage Therapy, Aesthetics or Nail Technology.

Emergency Contact (Family Reference information Only)
Name	Relationship
Street Address	Suite / Appt#
City	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip	Phone

Note
I certify that all of the above information is correct to the best of my knowledge. If accepted as a student by the school, I agree that during such time as I may be enrolled as a student, I will abide by all the rules, regulations, practices and policies of the school as they may be at the time of admission or as they may be changed during my continuance as a student. Furthermore, I authorize the school to cross-reference any and all information I have provided to them. I understand that my information will be kept private and not released without my written consent, unless required by law. Universal Spa Training Academy adheres to the principle of equal education opportunity without regard to race, handicap, sex, color, creed, or national origin.

Have you ever been convicted of any crime, including felony, misdemeanor, or sexual offense *	Yes     No
I understand and agree to the terms listed under the section titled: Note *