Cosmetology Application Form


Please use the TAB key to scroll through the fields.

Select Your Perferred Start Date: August January May

Name:

(First)
(Middle)
(Last)
(Maiden/Other)

Date of Birth: Space Social Security Number:

Address:

(City)
(State)
(Zip Code)

Home Phone: Cell or Msg Phone:

High School/GED Graduation Date: Space High School GED

Have you previously attended CCCUA? Yes No
If yes, please give date(s):

Are you currently enrolled at CCCUA? Yes No

Do you have Cosmetology hours to transfer in? Space Yes No
If Yes, School Attended: Space and hours to transfer:

I hereby authorize CCCUA to share my academic and personal information with the Arkansas Department of Health, Cosmetology Section for the purpose of verifying my educational credentials and legal right to attend a cosmetology program.

This is a secure web site. If you do not want your personal information transmitted via the internet, please call or write the CCCUA Cosmetology department to have an application sent to you.

If you do not object to your personal information being transmitted via the Internet then complete the form and click the "Submit" button.

By clicking the "Agree & Submit" button, I understand that I am electronically "signing" this document.