Aesthetic Laser Training Academy Application Form

First Name*:

Last Name*:

Phone Number*:

Cell Phone Number:

Your Email*:

Date of Birth*:

Gender*:
MaleFemale

Address*:

City*:

Province*:

Postal Code*:

Occupation*:

Employer Name*:

Employer Contact Number*:

Level(s) of Education*:
High School DiplomaCollege DiplomaUniversity Degree

Provide Details*:

Do you have any medical or health concerns?*
YesNo

Please specify:

Please check any of the health conditions that pertain to you*:
DiabetesPregnancyHeartStrokeSeizuresAsthmaDepression/AnxietyArthritisBlood DisordersLiver Disease

Please communicate any allergies*:
YesNo

If yes, please specify:

First Name*:

Last Name*:

Phone Number*:

Cell Phone Number:

Your Email*:

Postal Code*:

Address*:

City*:

Province*:

Please provide 2 references: (Ideally employers, teachers, or colleagues)

Reference 1

First Name*:

Last Name*:

Contact Number*:

Email Address*:

Reference 2

First Name*:

Last Name*:

Contact Number*:

Email Address*:

Please explain why you would like to take a laser training course*:

What are you hoping to achieve with this training program?*

Please identify your personal strengths and weaknesses*:

Please provide the following:

Copy of your degree or diploma of your highest level of education*:

Criminal record check*:

Up-to-date CV*:

Immunization record*: