Aesthetic Laser Training Academy Application FormHome» Aesthetic Laser Training Academy Application Form Personal Information 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*: Education Information Level(s) of Education*: High School DiplomaCollege DiplomaUniversity Degree Provide Details*: Personal Health 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: Emergency Contact First Name*: Last Name*: Phone Number*: Cell Phone Number: Your Email*: Postal Code*: Address*: City*: Province*: References 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*: Interest 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*: General Information 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*: Statement of Authenticity*: By checking this box, you are attesting that the above information is accurate and true. We will be contacting you in 2 weeks upon receipt of this application for an interview. Lead status Your browser does not support JavaScript!. Please enable javascript in your browser in order to get form work properly.