Application

Campus Preference:*

Program:*

Desired Start Date*

Contact Information

Legal First Name:*

Legal Last Name:*

Preferred Name:

Social Security Number:*

Legal Gender*

Gender Preferred:

Pronouns Preferred:

Birth Date:

Mobile:*

Email Address:*

Personal Information

Ethnicity*

If other: Please specify:

Citizenship*

If not a US Citizen - Visa Number:

Place of Birth:*

Additional Information

Marital Status:*

How do you plan on paying for school?*

Do you have a GED?*

Are you a dependent?*

Do you have any dependents?*

Do you have GI Bill Benefits?*

ADA Accommodations:

Do you have Transfer Hours?*

Dominant Hand:*

Primary Address

Country:*

State:*

Zipcode:*

City:*

Address:*

Emergency Contact Information

Emergency Contact Full Name*

Emergency Contact: Relationship*

Emergency Contact: Cell Phone Carrier

Emergency Contact: Email*

Emergency Contact: Cell Phone Number*

References

Reference 1: Full Name*

Reference 1: Relationship*

Reference 1: Phone*

Reference 1: Email*

Reference 2: Full Name

Reference 2: Relationship

Reference 2: Phone

Reference 2: Email

Reference 3: Full Name

Reference 3: Relationship

Reference 3: Phone

Reference 3: Email

By submitting this form, I agree that Cinta Aveda Insitute may call, text and/or email me about their educational services at the contact information provided, including a wireless number, using automated technology. Please note, I understand that this consent is not required to attend the Cinta Aveda Institute and I may withdraw my consent to such contact. Message and data rates may apply. Text STOP to opt out or HELP for help.