Dudley Beauty School System Application

DUDLEY BEAUTY SCHOOL SYSTEM

Application for Admission
(Printable form for FAX submission or via US Mail -- Please Type or Print)

Full Name: ___________________________________________________ Social Security Number _____ - ___ - _____
Last Name_________________________________ First Name _____________________ Middle Name_____________
Address: __________________________________________________________ _______________ ______ _________
Street/PO Box City State Zip
Telephone: Home (_____)_____-______ Work (_____)_____-______ Date of Birth: ____/____/____
Email Address: _____________________________________________

Sex	Ethnic Group	Citizenship
[ ] Male	[ ] African American	[ ] United States Citizen
[ ] Female	[ ] Asian or Pacific Islander	[ ] United States Permanent Resident
	[ ] Caucasian	(enclose a copy of your resident alien card, front & back)
Veteran	[ ] Hispanic	[ ] Not a United States Citizen or Permanent Resident
[ ] Yes	[ ] Native American
[ ] No	[ ] Other

Course of Study		Campus of Choice
[ ] General Cosmetology	[ ] Teacher Training (Cosmetology)	[ ] Charlotte, NC	[ ] Kernersville, NC
[ ] Manicuring/Onyxology	[ ] Teacher Training (Manicuring/Onyxology)	[ ] Chicago, IL	[ ] Washington, D.C.
[ ] Esthetics/Skin Care*	[ ] Teacher Training* (Esthetics)	[ ] Durham, NC
[ ] Manager		[ ] Greensboro, NC

The following information is required by the National Accreding Commission of Cosmetology Arts & Sciences:

Age	Family Income	Marital Status
[ ] Under 20	[ ] $0 - $9,999	[ ] Divorced/Widowed
[ ] 20 - 23	[ ] $10,000 - $19,999	[ ] Married
[ ] 24 - 29	[ ] $20,000 - $29,999	[ ] Single
[ ] 30 - 39	[ ] $30,000 and over
[ ] 40 and over

Number of Dependents: _______ Male ______ Female

Have you previously obtained credit hours? [ ] Yes [ ] No
If yes: Where______________________________ When_______________ Number of Hours________________
Please have a transcipt sent to our school verifying hours and live model performances. If previous school is in another state, please request
a Board Certification letter from your cosmetology board be sent to our school.

Who referred you to the Dudley Beauty School System, Inc.?________________________________________________
How did you hear about the Dudley Beauty School System, Inc.?_____________________________________________

EMERGENCY INFORMATION (Person to notify in case of an emergency)
Name______________________________________Address_________________________________________________
Telephone (day)____-____-______ Telephone (evening)____-____-______ Relationship____________________________

Do you have an infectious condition or illness that would affect your ability to service a client? [ ]Yes [ ]No

If yes, please provide details____________________________________________________________________________

* Charlotte, Chicago, Greensboro, Kernersville campuses only ** Washington campus only

The Dudley Beauty School System, Inc. is committed to equality of eductional opportunity and does not discriminate against applicants, students or its employees based on age, creed, color, race, religion, sex, handicap or ethnic origin. The Dudley Beauty School System, Inc. is open to everyone and no person will be denied admission, graduation or any other rights and pfivileges of Dudley Beauty College(s) or Dudley Cosmetology University because of discrimination.

Please complete the second page of the Application for Admission Form (page 2)

Dudley Products, Inc.
1080 Old Greensboro Rd.
Kernersville, NC 27284
Phone: 336-993-8800
Fax: 336-993-1768
email: dudleysqplus@worldnet.att.net