Registration (Koe Barber Academy)

KOE Barber Academy

437 S. Central Ave

Lakeland, Florida 33815

863-374-2391

or

863-500-7773

Application Form

Non-Refundable Registration Fee $150.00
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent/Guardian (if student is under 18)
Phone Number*

Area CodePhone Number
SS Number
Date of Birth
Drivers License (State/Number)
Have you ever been arrested or convicted? If yes, please explain*

YesNo
Program Type:*

Full TimePart TimeDay ClassesNight Class
What are you looking for in a school?*
Class Schedule:*

YesNo
Emergency Contact (who should be contacted incase of an emergency)*
Email*
example@example.com
Contact Name*
Relationship to you*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Day Time Phone
Evening Phone
Religious beliefs that will allow you to not perform any services in this industry? Yes or No. If yes, please explain.
Applicant's Education and Training
College/University Name and Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Did you receive a degree? If yes, degree received:
High School/GED Name and Address
Did you receive a diploma?*

YesNo
Other Training (graduate, technical, vocational):
Shirt Size*

SMLXLXXLXXXL
I certify that the information provide on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application.
Signature*
Date
Should be Empty: