Full Name

E-mail Address

Phone Number

Application for Individual Licensed Professional Account

Name of Licensed Professional (as appears on license)

Address Line 1

Address Line 2

City

State

Zip Code

State of Professional License

Type of License

License Number

License Expiration Date

Application for Business Account

Name of Business

Business E-mail Address

Business Phone Number

Business Address Line 1

Business Address Line 2

Business City

Business State

Business Zip Code

Business TAX ID or EIN

Type of Business

Name of Contact Person

Application for Esthetic Student Account

*currently enrolled or recent graduate of cosmetology or (a)esthetics program but not yet licensed

Name of the School

School Phone Number

School Address Line 1

School Address Line 2

School City

School State

School Zip Code

Type of program enrolled in or graduated from

Total course hours

Current hours completed

Expected graduation/licensure date