Untitled Form

Request for Informational Interview
(Fields with asterisk (*) are required.)

Name* First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code
Home Phone - (###) - ### ####
Work Phone - (###) - ### ####
Cell Phone - (###) - ### ####
Email
Preferred Contact Method* Home Phone Work Phone Cell Phone Email
Date of Birth / MM / DD YYYY
Program(s) of Interest* Cosmetology - Day Program Cosmetology - Night Program Esthiology - Day Program Esthiology - Night Program
(Select all that apply)
How did you hear about us?*
Select each of the days you are available for an appointment:* Monday Tuesday Wednesday Thursday Friday
(Select all that apply)
Select each of the times you are available:* 9:00 am 10:00 am 11:00 am 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm
(Select all that apply)

2828 N. Clark Street • Chicago, Illinois 60657 • 1-773-883-1560